diff --git a/.DS_Store b/.DS_Store new file mode 100644 index 0000000..04481f4 Binary files /dev/null and b/.DS_Store differ diff --git a/data/complaints.csv b/data/complaints.csv new file mode 100644 index 0000000..1f5c19b --- /dev/null +++ b/data/complaints.csv @@ -0,0 +1,10009 @@ +complaint_id,facility_id,facility_type,incident_date,notes,severity,fine,Facility Invest Results Abuse,Facility Invest Results Rule,Type Of Abuse +OT105179A,385008,NF,8/31/2010,"RV reported asking staff to change him/her prior to transport to a medical appointment, but the transfer occurred before staff changed RV. RV reported staff did not have the specific adaptive device to prevent the incontinence. W1 reported the device was moved to another location in RV's room and staff were unable to locate the device. RV reported being embarrassed and humiliated by having a ""wet crotch"". RV's care plan was not followed. RV was not afforded all due respect and dignity. Staff are encouraging RV to make his/her feelings known to RP staff and facility administration.",2,0,Not Substantiated,Substantiated, +OT105179B,385008,NF,8/31/2010,"RV reported staff answered his/her call light, but failed to return before RV experienced bowel incontinence. RV reported feeling embarrassed and humiliated. RV was uncertain if the bowel movement came in a short period of time. Record review found RV receiving a 3 day intervention treatment for bowel care per RV's own request. Staff failed to return in a timely manner to assist RV to the bathroom.",2,0,Not Substantiated,Substantiated, +OT105179C,385008,NF,8/31/2010,"RV reported an unknown ""not RV's regular staff"" failed to provide RV's anti-anxiety medication in a timely manner and ""taunted"" RV at the time the medication was provided. Record review revealed RV received the medication twice on 8/20/10, once on 8/21/10 and again on 8/23/10 with good results. Staff unfamiliar with RV delayed delivery of RV's anti-anxiety medication. Evidence fails to support the alleged ""mocking"" or ""taunting"". Staff are encouraging RV to report his/her concerns.",2,0,Not Substantiated,Substantiated, +OR0000656000,385008,NF,12/21/2010,"Resident 1 was admitted with multiple diagnoses including a left below knee amputation (LBKA) and a right partial foot amputation. Resident 1's MDS of 11-10-10 revealed Resident 1 required extensive 2 person assistance with transfers. Resident 1's bedside information sheet dated 11/5/10 noted the ""maximum"" for assistance. Staff 7 failed to hold Resident 1's gait belt during a transfer and Resident 1 fell opening the LBKA suture line. Resident 1 required hospitalization and surgical revision. Staff 7 reported Resident 1's gait belt was not accessible due to the walker and wheel chair being in the way. Resident 1's care plan was revised to use a two person assist at all times with staff holding the gait belt. All staff received further in-service. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OT105397,385008,NF,9/17/2010,"RV was admitted 9/17/10 with multiple diagnoses, physician orders including therapy services and critical medication for blood thinners. RV did not receive anti-coagulants for lab work as ordered from 9/17/10 through 9/24/10. Although RV did not sustain a noted negative outcome, RV was at risk for developing blood clots. The facility instituted change in policy and procedure to prevent a similar future event.",2,0,Not Substantiated,Substantiated, +OT129247,385008,NF,2/6/2012,"RV reported RP2 told RV he/she would take call light away if RV pushed the call button again. RV reported RP2 would turn call light off and return later. W1 reported earlier in the month RP2 became ""frustrated, and abrasive when lack of timely response"" was pointed out. W1 reported evenings are busy "" staffing may be an issue"". W3 reported RV is hard of hearing and may need additional time to process what is said. RP2 denied telling RV RP2 would take call light away. RP2 did turn the call light off and finish the requested task later. RP2 reported W3 counseled RP2 that RP2 may need to slow down. The facility failure to respond to RV's request in reasonable length of time represents a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000757100,385008,NF,4/18/2012,"Resident 8's 4/20/2012 PRN MAR revealed no Tramadol was used from 4/12/2012 to 4/13/2012. Resident 8 received Tramadol on 4/14 & 15/2012 for right thigh pain, right hip pain, lower right extremity pain and lower back pain. Resident 8 was sent to the hospital on 4/15/2012 for evaluation and found to have a right hip fracture of unknown origin. The facility investigation found it unlikely the resident sustained an unreported fall due to the amount of assistance it would have taken to lift resident from the floor. The investigation failed to identify any staff interviews or if the resident care plan required a change. Relevant portions of the survey are attached. There was proposed enforcement action. The facility failure was identified as an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OT150737,385008,NF,10/13/2012,"The facility failed to ensure adequate staff instruction/supervision regarding use of hot packs; specifically parameters of use for residents and identifying staff professionals allowed to use the hot pack. RP2 (a licensed nurse) instructed W5(C.N.A.) to place a hot pack to RV's shoulder area. W5 acted outside his/her scope of practice and RP2 failed to have the authority in this facility setting to delegate to W5. RV sustained a second degree burn to the area in which the hot pack was applied. Facility failure to provide adequate policy and procedure; and staff instruction regarding hot packs resulting in neglect of care and resident harm constitutes abuse. A Civil Penalty in the amount of $ 400.00 would be imposed. Due to the date between the investigation report and date of delivery of the report for review, no sanction will be imposed. The finding of abuse will stand in the facility history. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OT120442,385008,NF,6/18/2012,"RV choked on meat not thoroughly pureed as RV's physician ordered. RP2 believed the meat was pureed, but the method used to check the consistency of the meat was inadequate. RP2 was counseled and the process to ensure food is of adequate texture was changed. The facility failure resulting in harm and even great potential harm constitutes neglect and abuse. A civil monetary penalty will not be issued as the investigation report was submitted three years after the investigation was completed. The investigation will be part of the facility's history. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +BC116216,385010,NF,12/30/2010,"RV reported someone, unknown staff or hospice, pulled RV up in bed causing pain. RV did sustain a bruise of unknown origin. RV does have a history flailing and banging against side rails at times, but W5 stated this behavior had stopped. RV's care plan addressed transfer assist and weekly skin checks due to fragile skin. Initially RV was not care planned for gait belt transfers.",2,0,Not Substantiated,Substantiated, +OR0000685900,385010,NF,4/27/2011,"Resident 1 was admitted with multiple diagnoses including CVA, right sided hemiplegia, aphasia, CHF, cognitive impairment, etc. Resident 1 was dependent for all ADLs and was non-ambulatory, but would wheel his/her wheel chair using his/her left arm. Resident 1 was assessed at risk for falls. Resident 1 fell 12/8/10 & 3/25/11 with his/her care plan revised to include non slide pad in the wheel chair, bed side alarms and floor pads. At the time of Resident 1's fall from his/her wheel chair (4/25/11) the wheel chair foot rests had been removed. After the fact staff reported the wheel chair with out the foot rests would have made Resident 1's balance less stable. Staff 4 reported the foot rests were removed at Resident 1's request and Resident 1's feet were dangling without the foot rests. The charge nurse was not notified of Resident 1's preference to have the foot rests removed. At the time of the fall Resident 1 was left alone in the wheel chair. Resident 1 fell and sustained injury including a later identified hip fracture. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000685901,385010,NF,4/27/2011,"Staff failed to adequately assess and document the health status of Resident 1 who experienced a change of condition including a fractured hip with on going pain. Resident 1's assessment following the 4/25/11 fall did not include assessment of Resident 1's ROM (range of motion) of his/her extremities or assessment for other indication of extremity injury. Staff 7 documented Resident 1's complaint of pain and continued complaint of right hip pain on 4/26/11, but failed to request an x-ray until later in the day. Resident 1 was transferred to the hospital at 7:10 P.M. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000685902,385010,NF,4/27/2011,Resident 1 fell on 4/25/11 at approximately 8:45 P.M. Staff failed to promptly notify family members of the fall. Family was notified of the fall at 8:25 A.M. on 4/26/11. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +BC117884,385010,NF,7/18/2011,"Facility staff failed to verify if a physician ordered lab work (drawn 7/13/2011) was completed prior to reordering the same test (drawn 7/18/2011). RV sustained an unnecessary second blood draw, emotional distress, physical discomfort/pain and sustained a ""grossly"" discolored forearm where the blood draw was completed. The incident would have been prevented had staff double checked physician orders, verified if the original ordered lab work had been drawn and had listened to the RV. The facility changed the policy following this event to include the RCM must double check the physician orders.",3,200,Substantiated,Substantiated,Neglect +BC117864,385010,NF,8/29/2011,"RP2 failed to honor RV's choice in care; and failed to back away from RV's care resulting in RV's increased agitation, striking out and ultimately sustaining injury to RV's wrists. W3 entered RV's room after hearing shouting, found RV ""clutching"" his/'her wrist and saying it ""hurts."" W3 reported noting discoloration of ""the area."" RP2 reported he/she was attempting to ""block"" RV's blows. RP2 wrote a statement on 8/29/2011 that I ""hold"" RV's ""hand cuz"" RV was almost hitting me and I told RV don't hit me. During an informal conference held on 1/31/2012, RP2 provided further clarification, stating she/he blocked RV's blows, but held RV's hands as RV was attempting to transfer and was unsteady. RP2 reported RV had refused use of the gait belt once and was attempting a second unsteady transfer. W2 reported staff is aware of a universal protocol to leave an agitated resident and re-approach. RP2 acknowledged he/she should have left RV when RV was agitated, but was afraid RV would fall.",2,0,Not Substantiated,Substantiated,Neglect +BC146085B,385010,NF,12/28/2013,"RV reported being happy with his/her care. W1 reported the facility has a new medication tracking system; the physician changed RV's medication, but the system did not make the changes; and a medication error occurred. The error was discovered and RP2 change the medication in the system without fully clarifying the physician order. RV's physician said an error really did not occur and RV was fine. RV did not sustain harm. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC152889,385010,NF,9/20/2015,"Evidence and interviews indicated facility failure to adequately plan Resident #1_x001A_s discharge from the facility and denial to readmit Resident #1 on or about 9/20/2015. Progress notes indicated Resident #1 was discharged with an infection to her/his leg and she/he was unable to wear a prosthetic because of the infection. Witness #2 indicated Resident #1 was assisted home to her/his second floor apartment where she/he subsequently fell and spent the night sleeping on the floor. + +According to witness #6 (facility staff), Resident #1 asked to return to the facility on or about 9/20/2015 and witness #6 said Resident #1 could not return to the facility once she/he had been discharged. On 9/21/2015, Resident #1 was transported to the emergency department (ED) of the hospital and sent back home. Documentation indicated Resident #1 was transported back to the hospital ED on 9/22/2015. Resident #1 remained in the hospital ED until 10/6/2015 when admitted to a different nursing facility.",3,800,Not Substantiated,Substantiated, +BC116277,385015,NF,1/6/2011,"Staff failed to follow RV's wound care orders on 1/01 & 02/2011. Facility nurses thought it was ""their duty"" to ""go along"" with family wishes for RV's care per W1. Staff followed ""old"" wound care orders and RV did not sustain harm per W1. W2 reported RV's care plan does not mention a guardian or Healthcare POA. RV is unable to respond to questions due to his/her medical condition. The facility has changed it's policy as a result of this incident.",2,0,Not Substantiated,Substantiated, +BC116904,385015,NF,4/30/2011,"W1 overheard RP2 ""yelling"" at RV,""if you don't stop I am going to spank you"". RV showed no sign of physical trauma. RP2 left RV's room at W1's direction. RP2 was prohibited from providing care to RV the rest of the shift. RP2 reported talking to self while providing care to RV, ""if you were my child I would spank you."" RP2 failed to treat RV with all due respect by talking to self in what could have been an intimidating manner to RV. RP2 reported the facility protocol is to re-approach a resistive resident, but RP2 failed to follow the protocol or inform the charge nurse of RV's behaviors. RP2 failed to follow RV's care plan to approach RV in a calm manner. RV was upset and combative after the incident.",2,0,Not Substantiated,Substantiated, +BC118020A,385015,NF,9/16/2011,"RP2 took photographs of RV1, RV2 and RV3 without their permission. RP2 posted the pictures to face book without RV1, RV2 or RV3's permission. The photographs which included RV1, RV2 and RV3 in various poses of undress and or very poor grooming were accompanied by written deleterious comments. RV2 and RV3 expressed embarrassment and or concern that their pictures were out on the internet. While RV1 was unable to give relevant information, a reasonable person would consider RP2's actions offensive. RV1, RV2 and RV3 sustained significant loss of dignity due to RP2's actions.",2,0,Not Substantiated,Substantiated,Neglect +BC118020B,385015,NF,9/16/2011,"While photographs were taken and displayed of RV1's gown tied in a knot about RV1' briefs, evidence is insufficient to support who may have tied the gown about the briefs. Evidence is insufficient to support facility failure to prevent RV1 from use of physical restraint. Evidence does support failure to follow RV1's care plan use of a onesie or lap buddy to deter RV's touching him/herself while out in a public place and during the time the photographs were taken..",2,0,Not Substantiated,Substantiated, +OR0000713700,385015,NF,9/7/2011,"Resident 1 was admitted 2/28/2011 with multiple diagnoses. On 3/15/2011 resident's physician ordered an anti hypertensive medication to be given three times per day with specific parameters for giving the medication. On 9/6/2011 Staff 2 (RP2) gave the anti hypertensive medication without following the parameters or checking the MAR to see if the medication was already given; went by what the resident said. Resident 1 had received the anti hypertensive medication less than an hour before Staff 2 administered the medication. Resident's physician was notified, resident was monitored and sent to the ER when his/her pulse rate dropped. The facility reported Staff 2 to OSBN, provided further education and began supervision of Staff 2 when Staff 2 gave any oral medication. Relevant portions of the survey are attached. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +BC129333,385015,NF,1/3/2012,"RP2 requested W1 to hold RV's arm while administering an injection. RP2 reported always being careful regarding RV's care; asking which finger to use for CBG and where RV wanted the injection. RP2 does not recall this particular event, but RV requested wanting to ask a question prior to receiving care and was upset. W1 held RV's arm at the direction of RP2 who was W1's supervisor. While some residents are care planned to have their arm held during an injection; RV was not. RP2 failed to give RV all due respect during his/her care resulting in a violation of resident rights. This failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated, +OR0000751802,385015,NF,3/26/2012,"Resident 1 was admitted the facility with medication orders and specific physician orders not to use incontinence briefs. Resident orders were followed except placement of a incontinence brief 3/25/2012 night shift. Staff1 reported placing the brief post bowel care having forgotten staff were not to place a brief. Staff 2 also placed a new brief on day shift prior to reviewing resident 's care plan. Staff 3 reported the redness on Resident 1's right buttocks was excoriation; no bleeding or rash found. The facility failure to follow resident's care plan represents a Oregon Administrative Rule violation as well as, a federal deficiency. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +OR0000763800,385015,NF,5/24/2012,"Resident 1 was admitted to the facility April 2012 with multiple diagnoses. Resident 's physician orders included CBG and notifying the physician with certain parameters for the CBGs. On 5/23/2012 Resident 1 received another resident's medication, staff notified the physician, monitored the resident and notified the physician of there resident's change of condition. Resident 1 was sent for further evaluation. The facility failed to ensure Resident 1 received medication according to physician orders. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +BC121283,385015,NF,8/17/2012,"RV receives a PRN anti-emetic medication prior to a specific treatment, but RP2 forgot to give RV the medication. RV also receives other anti-emetic medication on a regular. While RV experience some emesis, this occurred on another shift than when the PRN medication was to be given, so a clear link between failure to give the PRN and the emesis can not be drawn. s RV did not receive all medication as ordered. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000810501,385015,NF,2/8/2013,Resident 1 was admitted 12/4/2012 with multiple diagnoses. Staff failed to make a home health referral as resident physician ordered. Staff 3 reported not making the referral as the resident went to the ostomy clinic twice a week. Relevant portions of the survey are attached. Federal enforcement action was proposed. An Oregon Administrative Rule Violation occurred.,2,0,Not Substantiated,Substantiated, +BC133041,385015,NF,4/1/2013,"During interviews with witnesses and RV it was determined RV lost money from his/her locked drawer. RV reported keeping the key on his/her wrist. RV will give the key to staff to unlock the drawer and get money for sodas, etc. The facility replaced the missing money and RV is now using a money pouch. Staff will check to see that RV has the pouch on.'",2,0,Substantiated,Substantiated,Financial abuse +OR0000854200,385015,NF,9/24/2013,Resident 1 was admitted May 2013 with multiple diagnoses. The resident was admitted for rehabilitation following cardiac surgery. The resident POLST listed specific parameters. On 5/16/2013 resident sustained a change of condition without appropriate notification to resident physician. Relevant survey pages are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Inconclusive,Substantiated, +OR0000854201,385015,NF,9/24/2013,The facility failed to administer resident medication according to physician orders and obtain parameters for administration of antihypertensive medication. The resident was placed at risk for harm relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Inconclusive,Substantiated, +OR0000923600,385015,NF,9/24/2014,"Resident 1 was admitted in 2013 with multiple diagnoses. In August of 2014 the resident had orders for care services related to tube feedings. Staff monitored and provided care/feedings. On occasion the resident's feeding tube became clogged despite staff providing appropriate care per resident, witness and staff/document review. The resident's feeding tube was changed; there was no further clogging as of 12/21/2014. During the investigation it was discovered the facility failed to follow physician orders regarding cc's of pedialyte from 10/21/ to 10/31/2014. No evidence of negative outcome to the resident was discovered. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC151265,385015,NF,3/12/2015,"On 3/12/2105 W3 (family) realized and reported to staff RV was not wearing his/her sapphire ring. RV has been a resident since 2014, is a little forgetful, almost blind and has never removed the ring in the past. Witnesses deny RV has sustained any significant weight loss which would allow the ring to simply slip off. RV's roommate had considerable company 2/19/2015. Staff searched the facility, but the ring has not turned up. No one really knows what happened to the ring. W3 reported the only other thing RV had go missing was some cookies. The facility reimbursed for the missing ring. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +OR0001020805,385015,NF,10/26/2015,Resident 2 was admitted 10/21/2015 with diagnoses including abdominal surgery due to diverticulitis. The complainant indicated the linoleum was coming loose and moldy smell was in the facility. Staff 5 and 14 are aware of the e issue and are in the process of obtaining bids for remodeling. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +BC165031,385015,NF,3/12/2016,"Documentation and interviews indicated RP2 (Johnny W. McGee) yelled at RV; and threatened to ""kill RV and told RV put you six feet under"". RV stated RP2 is not nice, RP2 is not gentle and reported RP2 said ""the next time I will kill you"". RP2's verbiage constitutes mental abuse by threats of punishment. The facility took appropriate and immediate action. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +OR0000667900,385018,NF,2/10/2011,"Resident 1 was admitted 12/20/2010 with diagnoses of bilateral below knee amputation. Resident 1 fell in his/her room on 12/20/2010. Further assessment and intervention included a low bed, floor mats and a TAB alarm at all times. Resident 1 fell on 2/12/2011 at 3:45 and did not have the alarm on at the time of the fall. Resident 1 did not sustain injury. Staff 1 had found Resident 1 without an alarm at the beginning of his/her shift, was unable to tell the charge nurse at the time, got busy and forgot to follow through. All staff including Staff 1 received re-education in-service on following the care plan and how to respond if a necessary item was not available. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +OR0000711400,385018,NF,8/26/2011,"Resident 1 was admitted 8/20/11 with multiple diagnoses. Resident 1's admission assessment indicated bruising to his/her right hand, right shoulder and left forearm. On 8/22/11 staff note of 2:20 P.M. indicated deep purple bruising to Resident 1's penis, fore skin and scrotum; not related to injury. Multiple staff indicated there were no investigations by staff for the origin on Resident 1's bruising. Staff denied any knowledge of mistreatment. Relevant survey portions are attached.",2,0,Not Substantiated,Substantiated, +WB118529,385018,NF,11/20/2011,"W1 and W2 observed RP2 and RV by the storage room. W2 overheard conversation between RV and RP2. W1 observed RP2 attempting to keep RV out of the storage room. W1 reported RV and RP2 were ""struggling""; RP2 was holding RV's wrist. W1 reported asking RV to go to the dining room and RV complied. W3 reported ""staff know"" RV goes into the storage room to be alone. RP2 gave a differing account of his/her interaction with RV; did state ""grabbing"" RV's wrists to keep RV from hitting RP2. Pictures of RV's wrists, taken by another official agency, showed reddish spots. RV's care plan revealed a need for frequent re-direction and close supervision; becomes aggressive at times. RV's care plan did not address RV's ""alone time"" or use of a specific area, i.e.. The storage room. Not all staff received sufficient training regarding RV's specific needs.",2,0,Substantiated,Substantiated,Physical Abuse +WB132309,385018,NF,1/16/2013,"RV's physician order of 1/6/2013 through 2/1/2013 for RV to be catheterized daily was not completed as ordered. Staff missed the order per W1. W2 reported RV sustained two UTIs between 1/16/2013 and 1/29/2013, but evidence is inconclusive the lack of daily catheterization was the direct cause of the UTIs. An Oregon Administrative Rule violation occurred.",2,0,Inconclusive,Substantiated, +WB134718,385018,NF,9/26/2013,"RV and RP2 give varied accounts of events involving RV's transfer. Evidence fails to support roughness and abuse. RP2 failed to follow appropriate transfer procedures. RV likely became ""scared"" when RP2 grabbed the back of RV's belt to keep RV from falling. RV's care plan was adjusted for safety to use two staff for transfers. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +WB134966A,385018,NF,10/31/2013,"RP2 removed RV's staples. RV did not sustain known harm, but was at risk for harm. RP2 worked outside his/her scope of practice and outside his/her job duties. RP2 admitted it was not in a CNA's ""job description"" and it was a ""bad move"". RP2 received written warning and was no longer assigned as a CNA or CMA. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +WB134971A,385018,NF,10/11/2013,RP2 attempted a straight catheterization on RV which was not in her job duties and beyond RP2's scope of practice. While RP2 is a CNA II the task of catheterization must be delegated. W3 and W4 were not accurate in allowing RP2 to provide catheterization of RV as Nursing Facility rules do not allow delegation nor was RP2 delegated to perform the task. RV was at risk for harm. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +WB134971B,385018,NF,10/11/2013,RP2 attempted a straight catheterization on RV which was not in her job duties and beyond RP2's scope of practice. While RP2 is a CNA II the task of catheterization must be delegated. W3 and W4 were not accurate in allowing RP2 to provide catheterization of RV as Nursing Facility rules do not allow delegation nor was RP2 delegated to perform the task. RV was at risk for harm. The facility to ensure all staff were instructed in the latest policy and procedure for resident safety regarding the scope and practice of CNA2s. RP2 did not document nor did any license staff document RP2's attempted catheterization of. RV did report some pain at RP2's attempted catheterization. Oregon Administrative Rules were violated.,2,,Substantiated,Substantiated,Neglect +WB134966B,385018,NF,10/31/2013,"RP2 was not qualified to remove RV's staples. W4 admitted ""watching"" RP2 remove two staples. W4 reported not being entirely sure of RP2's certification. W4 and RP2 placed RV at risk for harm. RP2 received a warning and will not be assigned CNA or CMA duties. Staff received further instruction. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +WB145608A,385018,NF,12/1/2013,"On December 2, 2013 RP2 failed to assess and provide intervention regarding RV1's un-bandage heel and reported fever for over three hours even after several reminders. RV's temperature rose to 102.4 degrees and it still took RP2 a long time to respond per witness statement. Witnesses reported at the shift start RP2 stated ""Forgive me if I am slow tonight, I have swelling of the brain"". RP2 should not have been providing care while impaired. The facility had prior reports regarding RP2's inability to finish duties and medication error. RP2's behavior and neglect of RV's care resulted in a significant delay of medical care for RV constituting neglect and abuse. The facility failed to provide a safe environment by allowing RP2 to provide care having had prior knowledge of RP2's behaviors and actions. The facility allowed RP2 to provide care while impaired resulting in a significant delay of medical attention for RV1. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",3,600,Substantiated,Substantiated,Neglect +WB145608B,385018,NF,12/1/2013,The facility and ultimately RP2 failed to properly assess and ensure RV2's CPAP was functioning. There was no known outcome to RV2. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +WB145608D,385018,NF,12/1/2013,RP2 incorrectly told RV4 that RV was going to the hospital causing RV anxiety. RP2 received an order for RV's anxiety at 1:30 A.M.. But failed to deliver the medication until 2:10 A.M. after being reminded that RV needed the medication. RV was at potential for harm. RP2 was disciplined. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +WB145608C,385018,NF,12/1/2013,"On December 2, 2013 RP2 failed to assess and provide timely care for RV3's leaking colostomy bag. W2 reported changing RV's clothes and bedding several times during the 3 to 4 hour delay. Witnesses reported at the shift start RP2 stated ""Forgive me if I am slow tonight, I have swelling of the brain"". RP2 should not have been providing care while impaired. The facility had prior reports regarding RP2's inability to finish duties and medication error. RP2's behavior and neglect of RV's care for 3 to 4 hours resulted in a significant loss of dignity and potential for serious harm to RV's skin. RV's skin was excoriated at the colostomy site. RP2's behaviors and actions resulted in neglect and abuse. The facility failed to provide a safe environment by allowing RP2 to provide care having had prior knowledge of RP2's behaviors and actions. The facility allowed RP2 to provide care while impaired resulting in a significant a loss of dignity and potential for serious harm to RV3. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +WB149265,385018,NF,11/8/2014,"RP2 denied telling RV ""I could slap your face"". Evidence is inconclusive whether or not RP2 snapped his/her fingers and whether or not this was a form of intimidation. Review indicates RP2 received prior counseling regarding resident interaction. RP2 is reminded to be mindful of interactions with all residents. Staff should have promptly reported their suspicion of abuse. Failure to promptly report suspected abuse placed RV and all resident at risk for harm. A Oregon Administrative Rule violation occurred.",2,,Inconclusive,Substantiated, +OR0000975700,385018,NF,6/12/2015,"Resident 1 was admitted March 2015 with multiple diagnoses including end stage renal disease. The resident was assessed as alert, oriented and able to direct his/her care. The resident 3/18/2015 assessment indicated the resident was admitted with an unstageable left outer ankle ulcer. Record review and interview note facility failure to document the left ankle ulcer on the bedside care plan and the resident did not receive all dressing changes as ordered. Thigh resident proform orders were not consistently in place and or documented as to the reason why it was not placed on 5/30/2015. The flow sheet indicated an open area to the left posterior thigh; nothing was on the 5/30/2015 TAR. The resident developed an open area in June, but no changes were noted on the care plan. The facility failed to provide care and services. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000975701,385018,NF,6/12/2015,"Resident 1 was admitted March 2015 with diagnoses including anxiety. The resident was admitted with physician orders for Lorazapam. The resident was assessed to be alert, oriented and able to direct his/her care, but was not included in discussion regarding the risks versus the benefit for the use of anti anxiety medication. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000975702,385018,NF,6/12/2015,"Resident 1 was admitted March 2015 with diagnoses including end stage renal disease. The resident was alert, oriented and able to direct his/her care. Record review and witness interview indicated staff bump the power switch accidently, the resident became upset and the resident accidently struck his/her arm on the chair sustaining a skin tear. The resident was involved in an interaction with Staff 3 and voiced dissatisfaction with care; complained of rough care and or verbal abuse, but then denied Staff 3 was rough. The facility failed to thoroughly investigate and document the allegations. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +MF116126,385024,NF,11/27/2010,"RV1 reported RP2 gave RV1 a ""macro mineral"" instead of a pain medication on 11/20/10.RV 1 reported telling the facility two times about medication issues. W2 reported filling out an incident report/grievance. W4 reported giving a baggy that RV1 spit a medication in to W1, but W1 disagrees with this statement. RP2 signed as giving RV1 a narcotic medication on 11/26,27 and 30/10. RV2 reported that on P.M. shift of 11/30/10 RV2 did not get RV2's blood gas checked or receive medication for blood sugars. RP2 reported the procedures were completed. Preponderance of evidence notes lack of facility follow-up to RV1's complaints. RP2 was terminated from employment for mismanagement of medication.",2,0,Not Substantiated,Substantiated, +OR0000692700,385024,NF,6/6/2011,"Resident 2 was admitted April 2011 with multiple diagnoses and the facility assessment revealed a reddened coccyx. Resident 2 was care planned to provide pressure relief measure including use of an air bed. Resident 2 was physically dependent for most ADLs. Resident 2's weekly pressure ulcer report dated 5/20/2011 revealed a 1x1 cm open area to the buttocks with generalized redness surrounding the area. The May TAR did not show treatment for the identified red area. Resident 2 was sent to the ER on 5/21/11 and the area was noted as untreated. Staff 4 reported filling out a wound record, but documentation was unable to be located. Multiple staff failed to measure, notify the physician or treat Resident 2's buttock wound. Relevant portions of the survey are attached. Enforcement was proposed including a Directed In-service.",2,0,Not Substantiated,Substantiated, +MF118672A,385024,NF,8/25/2011,"RV reported RP2 is harassing RV; RP2 had mental health come and evaluate RV. RV reported mental health did not find a problem. RV reported RP2 told RV he/she would be put on medication and at one time RP2 opened RV's door stating ""I heard you got evicted."" RP2 denies knowledge of any grievance filed against RP2 and denies saying anything about money to RV. W3 reported RP2 came up to RV, shook RV's buttocks and stated to RV that he/she was going to another facility. W4 reported RP2 spoke to RV in a condescending manner. W3 reported writing a grievance, but W1 denies any written complaints. W10 reported submitting a grievance to W6 , but W6 denies seeing any written grievance. W5, 6 and 9 deny seeing witnessing and or observing any inappropriate complaints. W1 did speak to RP2 regarding RP2 and RV's interactions. RP2 failed to treat RV with all due respect, but evidence fails to support RP2 verbally harassing RV.",2,0,Not Substantiated,Substantiated, +MF118672B,385024,NF,8/25/2011,"Witnesses, RV and RP2 give differing accounts regarding RV's scheduled 12/2/11 orthopedic appointment. RP2 and the facility failed to ensure appropriate transportation for the 12/2/11 appointment. RP2 rescheduled the appointment for 12/16/11. Evidence does not clearly identify whether or not the delayed appointment effect RV's out come. There was a delay in treatment with a potential for harm.",2,0,Not Substantiated,Substantiated, +OR0000743500,385024,NF,2/7/2012,"Resident 2 was admitted January 2012 with multiple diagnoses and care plan interventions addressing memory loss, fall risk, ADL assistance, etc. Nursing notes reveal from 1/19/2012 through 2/6/2012 resident repeated attempts to self transfer with an alarm in place to help alert staff. The facility failed to notify family of Resident 2's falls. The facility failure resulted in a violation of Oregon Administrative Rule violation. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +MS129175A,385024,NF,2/7/2012,Reported staff failure to answer RV's call light in a timely manner and when staff responded he/she waited almost 2 hours and called 911. W1 reported the evening RV called 911 there were three admissions. RV did not receive timely assistance to the toilet. This facility failure is a Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +MS129540,385024,NF,3/20/2012,"RP2 held RV's chin after RV attempted to bite and punched RP2. RP2 was assisting W1 and W2 while RV was combative with care. RV's combative behaviors were normal per W2. RP2 immediately stopped his/her actions when RV complained. RP2 had no similar past behaviors and said ""I should not have done that"". RV's care plan did not give specific interventions addressing RV's behaviors other than use two staff; nothing addressing RV's escalating behavior. The facility did begin to give all staff further in-service regarding intervention for distressing behaviors. The facility failure to properly train staff on working with residents and their behaviors resulted in loss of dignity for RV. This facility failure represents a violation of Oregon Administrative Rule.",2,0,Substantiated,Substantiated,Neglect +MF129424A,385024,NF,3/8/2012,"RV was admitted with multiple diagnoses and wounds. RV was unable to give relevant information. Witnesses give varied reasons for turning RV. W1, W2, W3 and W4 reported staff are not consistently turning RV as care planned. W9 worked with W3, W4 and facility head nurse to come up with care directives. W9, W10 and W11 reported RV's wounds are being treated and or healing ""slightly"". RV was not being turned consistently which represents a facility failure and Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +MF129424B,385024,NF,3/8/2012,"RV was unable to give reliable information. Witnesses reported that for a while no one realized RV could not eat by him/her self or have adequate access to his/her water. RV's nurse aide information sheet gave conflicting information regarding RV's care for feeding and turning. Hospice, staff and family have devised a plan for RV's care. The facility failure to adequately plan RV's care resulted in a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +MS120181C,385024,NF,6/1/2012,RV's PRN pain medication was delayed for 45 minutes on 5/29/2012. The complainant and witnesses reported the delay was due to shift change. RV does not recall the event and was not in pain at time of the interview. RV's medication was changed from PRN to a scheduled medication. The facility should have ensured timely delivery of RV's medication. The facility failure is an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +OR0000754700,385024,NF,4/6/2012,"Resident 1 was admitted February 2012 following exacerbation of CHF, bilateral pleural effusion and other diagnoses including decubitus ulcer. Resident's 2/12/2012 care plan did not include a problem for risk or actual pressure ulcer interventions. The 3/17/2012 MDS indicated an acquired Stage II pressure ulcer and resident required extensive assistance with ADLs, transfers, mobility, incontinence care, etc. W1 confirmed the facility informed him/her of the pressure ulcer. Weekly skin audit sheets were not consistently filled out. Resident's physician was not notified when the 3/3/2012 wound was identified. Not all treatment was initiated in a timely manner. The care plan was not up dated. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation was identified.",2,0,Not Substantiated,Substantiated,Neglect +OR0000754701,385024,NF,4/6/2012,"Resident 1 was admitted February 2012 following exacerbation of CHF, bilateral pleural effusion and other diagnoses including decubitus ulcer. Witnesses reported resident's discharge did not include pressure ulcer treatment or treatment and the resident arrived at the AFH without oxygen. Staff confirm the resident should have had oxygen during transport other AFH and there was no discharge paper work with wound care or oxygen use. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation was identified.",2,0,Not Substantiated,Substantiated,Neglect +OR0000765900,385024,NF,6/7/2012,"Resident 2 was admitted to the facility December 2011 with multiple diagnoses and behaviors. Resident was dependent for care including repositioning, transfers, etc. Resident's care plan included potential problem for Impaired Skin integrity due to episodes of bruising, but no care plan for pressure sores. RP2 developed two pressure areas without full assessment being documented nor a reassessment or an appropriate discharge plan. Relevant portions of the survey are attached. Enforcement action was proposed. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +MF120259,385024,NF,6/9/2012,RV was sent home without a PCP to call in case of an emergency or questions regarding medication. There was some miscommunication with W3 and W4. Home health was ordered and came out the day after RV's condition changed. While W3 and W4 reduced RV's medication and chose not to take RV to the ER when RV's condition changed; it may or may not have effected RV's outcome. RV's discharge plan was less than stellar placing RV at risk for harm. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +MS121216,385024,NF,9/19/2012,"The complainant reported RP2 was ""pushing"" RV1 and RV2 to stay in the nursing home. RV1 reported after telling RP2 a couple of time they moving, that RP2 should have dropped the subject. RP2 stated he/she would advocate for patients. W1 indicated RV1 was upset and worried about RP2's reaction to RV1 and RV2 moving. W3 reported RP2 was not proactive in assisting RV1 and RV2 to move to a AFH. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +MF121196,385024,NF,9/30/2012,"RV requested to leave the facility for overnight. The facility staff and in particular RP2 did not attempt to contact RV's physician for orders, but told RV that if RV left without physician orders it would be considered AMA. The facility failed to honor or attempt to honor RV's choice in care and or assist RV with obtaining appropriate discharge for over night visit. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +MS120939,385024,NF,8/25/2012,RP2 took RV's pendant and pawned the pendant without RV's knowledge or permission. RP2 was arrested. RV's pendant was recovered and returned to RV. The facility changed it's policy regarding resident monies and valuables; residents to use the facility safe. Reviewer notes residents have the right to keep personal property and be permitted to have a lockable storage space for personal property. The facility failure is an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated,Financial abuse +MS121916A,385024,NF,12/18/2012,"Staff told RV that RV had to learn to do for him/herself as RV was moving to Assisted Living Facility (ALF) and no one would be able to help RV. Staff deny letting RV struggle with a ""chore"" such as dressing before assisting RV. W 14 reported speaking with RV on 12/19/2012; explaining nursing staff were working with RV to help RV be as independent as possible. W 15 denied speaking to RV for three weeks. Regardless of who may have said exactly what, RV's impression was no one was going to help RV at the ALF and RV was very upset. RV's right to choose in his/her care and placement of care was compromised. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +MS121916B,385024,NF,12/18/2012,Staff failed to place sheets on RV's air mattress and RV was uncomfortable. Staff did not receive clear education for using sheets on RV's particular type of air mattress; believing no sheets were to be used. Staff received further in-service and RV received a new mattress with sheets. An Oregon Administrative Rule violation occurred..,2,0,Not Substantiated,Substantiated, +MS121910,385024,NF,11/13/2012,"Between October 2, 2012 and October 22, 2012 two hundred fifteen narcotic medications went missing from the facility. No residents were harmed, but potential for harm existed as the facility procedures for secure storage and accounting of narcotics failed. The missing narcotics were from resident narcotic medication being stored for disposal. A new policy and procedure was implemented in which staff counting the narcotic medication and writing in the narcotic log book must observe the medication and the log book together. Staff received further in-service regarding the new process. The facility failure constituted potential minor to moderate harm for all residents extending for multiple days. The facility failure is an Oregon Administrative Rule violation.",2,250,Not Substantiated,Substantiated, +MS132023A,385024,NF,11/19/2012,"On 11/21/2012 RP2 reported sitting to the left of RV1 and placing his/her hand on RV1's left shoulder because RV1 kept trying to stand up from his/her wheel chair. W 6 reported observing interaction between RP2 and RV1, stepping up and RP2 backing off care of RV1. W6 reported the next day RV1 had an oval purple spot on RV's neck; thought it was the right side; could have been the left side. Documentation noted an old yellowish bruise to the left side of RV1's neck the day after the reported event. Evidence is inconclusive RP2 was rough with RV1, but RP2 failed to treat RV1 with all due respect/choice in care. RP2 was asked to write an essay on working with people with dementia after receiving additional training. RP2 received the training, but has not written the essay. RP2 is out on leave. An Oregon Adminstrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +MS132023B,385024,NF,11/19/2012,"W4 reported observing RP2 ""yell"" at RV2 ""Hey that's not your room"". RV2 has a habit of wandering about the hallways in his/her wheel chair and is unable to give relevant information. W4 reported RP2 tipped RV2's wheel chair backwards while pulling RV2 from a resident's room. W4 intervened, telling RP2 he/she could not do what RP2 was doing, redirected RV2, provided redirection to RV2 and reporting the event to W5. RP2 reported redirecting RV2 two times and 3rd time did tilt the wheel chair. Evidence is inconclusive RP2 was rough with RV2, but RP2 failed to treat RV2 with all due respect/choice in care. RP2 was asked to write an essay on working with people with dementia after receiving additional training. RP2 received the training including not tipping a wheel chair as this is considered a form of restraint, but has not written the essay. RP2 was moved to another wing after this event. RP2 is out on leave. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +MS132023C,385024,NF,11/19/2012,"RV3 is cognitively impaired and has a history of being physically abusive, combative and an elopement risk. Rv5s' care plan noted wheel chair alarms and to re-approach when agitated. RP2 gave a different explanation to the occurrence than the anonymous complainant. RP2 reported pushing on RV3's shoulder blade to prevent RV3 from standing up out of the wheel chair on 1/102013 at 10:00 P.M. RP2 reported hurrying to RV3's room to keep RV3 from falling. RP2 was told by other staff that RP2's behavior was not appropriate and RP2 left the room. RP2 had not receive counseling at the time of the investigators interviews as the facility investigation was not yet complete. Evidence is inconclusive RP2 was rough with RV3, but RP2's care approach would indicate inappropriate standard of care. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +MS133114A,385024,NF,5/3/2013,Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 and Resident #2 related to unwitnessed falls with injury. Resident #1 and Resident #2 both sustained unwitnessed falls with injuries. These failures are considered neglect of care and constitute abuse.,3,900,Substantiated,Substantiated,Neglect +MS134572,385024,NF,9/30/2013,"Evidence and interviews indicated facility failure to adequately administer Resident #1_x001A_s anti-nausea medication as ordered. The facility failure to administer Resident #1_x001A_s anti-nausea medication as ordered resulting in Resident #1 sustaining repeated nausea are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +MS133904B,385024,NF,7/25/2013,"Evidence and interviews indicated facility failure to administer Resident #1_x001A_s nebulizer and breathing treatment as ordered. In addition, evidence and interviews indicated facility failure to administer Resident #1_x001A_s capillary blood glucose testing treatment as ordered.",2,,Not Substantiated,Substantiated, +MS133904C,385024,NF,7/25/2013,"Evidence and interviews indicated facility failure to provide Resident #1 adequate assistance with toileting. Resident #1 said she/he was _x001A_very humiliated_x001A_ and that she/he had wet the bed and declined an enema treatment because of inadequate assistance with toileting. The facility failure to provide Resident #1 adequate toileting assistance resulting in Resident #1 sustaining a serious loss of human dignity is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +OR0000856700,385024,NF,10/7/2013,"Evidence and interviews indicated facility failure to assure Resident #1 was offered water between meals. Witness #2 indicated Resident #1 fell while trying to reach water that was out of her/his reach. In addition, there were concerns with other residents not receiving water between meals.",2,,Not Substantiated,Substantiated, +OR0000863101,385024,NF,11/13/2013,Evidence and interviews indicated facility failure to utilize the services of a licensed pharmacist to ensure effective policy and procedures were established and implemented and medications were accurately received and dispensed to meet the needs of each resident. This failure placed residents at risk for not receiving timely medications as ordered. Relevant portions of the complaint report investigation are attached.,3,500,Not Substantiated,Substantiated, +MF148853C,385024,NF,10/9/2014,Evidence and interviews indicated facility failure to assure Resident #1's right to privacy related to an incident where Witness #6 (facility staff) forgot to knock before entering the bathroom while Resident #1 was changing her/his brief.,2,,Not Substantiated,Substantiated, +MF148853D,385024,NF,10/9/2014,Evidence and interviews indicated facility failure to timely provide Resident #1's physician ordered knee brace and bed rails and/or bed canes.,2,,Not Substantiated,Substantiated, +MF148853B,385024,NF,10/9/2014,"Evidence and interviews indicated facility failure to ensure the loss and/or theft of Resident #1's numerous personal possessions, mostly including clothing and cosmetics. Witness #2 (administrator) said replacement items would be purchased for Resident #1. Evidence and interviews indicated facility staff destroyed the narcotic pain medication Resident #1 had with her/him when admitted to the facility.",2,,Not Substantiated,Substantiated, +MS146941,385024,NF,5/1/2014,"On March 27, 2014 RP2 (licensed nurse) erroneously administered Resident #1 a narcotic pain medication, RP2 gave the medication to Resident #1 without identifying Resident #1 prior to administering the narcotic pain medication. Resident #1 had physician orders for a non-narcotic pain medication. Witness #1 took Resident #1 to a regularly scheduled physician appointment later that day she/he said the narcotic medication caused Resident #1 difficulty keeping her/his _x001A_head up._x001A_ The facility failure to administer Resident #1_x001A_s medication as ordered resulting in Resident #1 sustaining drowsiness are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +MS150275A,385024,NF,2/17/2015,Evidence and interviews indicated facility failure to ensure adequate medication administration for Resident #1. On 2/17/2015 RP2 (licensed nurse) erroneously administered Resident #1 an injectable medication prescribed to a different resident. RP2 identified the medication error and notified Resident #1's physician. Evidence and interviews failed to indicate Resident #1 had any ill effect from the 2/17/2015 medication error.,2,,Not Substantiated,Substantiated, +MS150275B,385024,NF,2/17/2015,"Evidence and interviews indicated facility failure to provide Resident #1's pain medication as ordered. The facility failure to administer Resident #1's pain medication as ordered resulting in Resident #1 sustaining unreasonable discomfort are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +MS151269,385024,NF,5/11/2015,"Evidence and interviews indicated facility failure to adequately care plan for Resident #2's known verbally aggressive behavior toward other residents. On 5/7 through 5/10/2015, Resident #2 screamed at Resident #1 causing Resident #1 to become distressed and withdrawn. On 5/11/2015, Resident #1 was moved out of the room she/he shared with Resident #2 and Resident #2 was no longer scheduled to share a room with other residents.",2,,Not Substantiated,Substantiated, +MS152574,385024,NF,8/25/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate assistance with toileting on or about 8/24/2015. The facility failure to ensure adequate toileting assistance, resulting in Resident #1 defecating in bed, are violations of resident rights, are considered neglect of care, and constitute abuse.",2,,Substantiated,Substantiated,Neglect +OR0001018500,385024,NF,10/21/2015,"Evidence and interviews indicated facility failure to assure Resident #2 the necessary care and services related to transfer assistance provided by staff #8 (CNA) on or about 10/6/2015. Staff #8 failed to use a gait belt or follow the care plan indicating two-person transfer assistance for Resident #2. The facility failure to ensure staff #8 followed Resident #2's care plan for transfers, resulting in Resident #2 falling and sustaining skin tears, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +OR0001021803,385024,NF,10/28/2015,"Evidence and interviews indicated facility failure to conduct an investigation regarding alleged rough treatment when staff were assisting Resident #3 with putting on shoes on or about 8/10 or 8/11/2015. Staff #6 said she/he spoke with Resident #3 about the allegation of alleged abuse and when speaking with Resident #3 she/he was unable to recall the incident and she/he was ""not fearful."" Staff #6 said she/he did not enter the allegation of rough treatment in the grievance log and she/he did not speak with staff or other residents, nor did she/he report the situation to administration. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001068200,385024,NF,2/25/2016,"Evidence and interviews indicated facility failure to accurately identify and monitor Resident #7's right heal blister, which became a Stage 3 pressure ulcer. The facility failure to adequately identify and monitor Resident #7's heal sore, resulting in Resident #7 sustaining full-thickness tissue loss, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000671200,385031,NF,2/24/2011,"Evidence and interviews indicated facility failed to implement care planned fall interventions for Resident #1. Resident #1 sustained a fall with injury requiring hospital treatment on February 22, 2011. Federal penalty recommended; relevant portions of the survey report are attached.",3,0,Substantiated,Substantiated,Neglect +OR0000679900,385031,NF,4/4/2011,Evidence and interviews indicated facility failed to provide adequate staffing to meet Resident #1's medical treatment needs. Relevant portions of the survey report attached; federal penalty recommended.,3,0,Substantiated,Substantiated,Neglect +OR0000679901,385031,NF,4/4/2011,Evidence and interviews indicated facility failed to provide care and services to manage Resident #1's pain. Relevant portions of survey report are attached; federal penalty recommended.,3,0,Substantiated,Substantiated,Neglect +BC117835,385031,NF,7/8/2011,"On 7/8/2011 RP2 (licensed nurse) gave Resident #1 three sleeping pills instead of Resident #1's ordered pain medication. Resident #1 said her/his pain was unrelieved but she/he slept in spite of the medication error. RP2 said Resident #1 was ""very groggy"" when RP2 woke Resident #1 to take her/his vitals. Evidence and interviews indicated facility failure to provide an adequate medication system.",2,0,Substantiated,Substantiated,Neglect +OR0000784700,385031,NF,9/19/2012,Evidence and interviews indicated facility failed to provide Resident #1 adequate care and services related to a change of condition. Relevant portions of the complaint report investigation are attached.,3,500,Not Substantiated,Substantiated, +OR0000784701,385031,NF,9/19/2012,Evidence and interviews indicated facility failed to notify Resident #1's family member regarding Resident #1's change of condition.,3,0,Not Substantiated,Substantiated, +OR0000818200,385031,NF,3/13/2013,Evidence and interviews indicated facility failure to ensure care planned fall interventions were available for Resident #6. Resident #6 had a fall on 03/11/2013 and sustained a head injury that required hospital treatment. Federal penalty recommended relevant portions of the complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000821702,385031,NF,4/2/2013,Evidence and interviews indicated facility failure to ensure warm water was available for showering/cleansing related to Resident #1's episode of incontinence.,2,0,Not Substantiated,Substantiated, +OR0000824300,385031,NF,4/17/2013,Evidence and interviews indicated facility failure to follow pressure ulcer care planned interventions and/or physician orders for treatment of pressure ulcers for Resident #2 and Resident #5. This failure placed residents' at risk of pressure ulcers worsening. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +OR0000828700,385031,NF,5/8/2013,Based on interviews and evidence it was determined the facility failed to ensure the physician and responsible party was timely notified of Resident #1's vomiting and episodes of non-responsiveness. This failure placed Resident #1 at risk of not receiving timely care and services. Relevant portions of the complaint report investigation are attached.,3,250,Not Substantiated,Substantiated, +BC134371,385031,NF,9/3/2013,"On or about 9/4/2013 one of Resident #1's family members reported that Resident #1's diamond ring and two anniversary rings were missing. Evidence and interviews indicated Resident #1's rings were probably removed from her/his hand while she/he was wearing them. It was not possible to rule out the possibility that a facility employee had taken Resident #1's rings. There was no value established for the stolen rings and no indication the facility provided restitution for Resident #1's stolen rings. Due to the age of the report at the time of processing, there was no civil penalty assessed regarding the incident.",3,,Not Substantiated,Substantiated,Financial abuse +BC135069,385031,NF,10/25/2013,"Based on interviews and evidence it was determined the facility failed to ensure RP2 (licensed nurse) administered Resident #1's medications as ordered. Witness #1 (licensed nurse) indicated RP2 had been sent to medication procedure training, however RP2 committed ""some"" medication errors after that training. + + + +The facility failure to ensure a safe medication system resulting in RP2 administering Resident #1's medications incorrectly and Resident #1 requiring hospital treatment are violations of resident rights, are considered neglect of care and constitute abuse.",2,200,Substantiated,Substantiated,Neglect +OR0000862400,385031,NF,11/7/2013,"Evidence and interviews indicated Witness #1 (former facility licensed nurse) failed to meet professional standards of care for Resident #1 when administering medications erroneously to Resident #1 resulting in Resident #1 being admitted to the hospital for treatment. In addition, evidence and interviews indicated facility failure to provide necessary care and services related to medication administration for Resident #4 and Resident #5. In addition, evidence and interviews indicated facility failure to meet professional standards of care for Resident #1 and Resident #5. The facility's failure to follow physician's orders for resident's medication administration resulting in Resident #1 requiring hospital treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000867801,385031,NF,12/27/2013,Evidence and interviews indicated facility failure to follow physician's orders related to Resident #1's feeding tube. Resident #1 had physician orders to receive feeding tube formula at the rate of 50 ml/hr. for 12 hours. A 04/10/2013 facility investigation indicated a certified nursing assistant found Resident #1 on her/his right side with emesis in her/his mouth. Facility staff observed Resident #1's feed tube formula was flowing and was attached to Resident #1 without being threaded through the pump. The pump (a machine that supplies formula at a scheduled rate per hour) was shut off and facility staff assessed and stabilized Resident #1. Nursing notes indicated that a chest x-ray was completed and was negative for aspiration pneumonia.,2,,Not Substantiated,Substantiated, +BC146380,385031,NF,3/8/2014,"Based on evidence and interviews it was determined the facility failed to provide Resident #1 adequate assessment and intervention with a change in the condition of Resident #1's feet. The facility failure to adequately assess and intervene with a changed condition of Resident #1's feet resulting in Resident #1 sustaining an ulcer on the top of her/his great left toe are violations of resident rights, are considered neglect of care and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +BC147726,385031,NF,7/2/2014,"Evidence and interviews indicated facility failure to ensure Resident #1 received adequate assistance with peri-care on 7/2/2014. Resident #1 had her/his call light on and was, ""calling for someone to get [her/him] cleaned-up."" Evidence and interviews indicated Resident #1 was observed by witness #3 (licensed nurse) to have emesis on her/his clothing at 10 am on 7/2/2014. Although several facility staff were aware Resident #1 needed assistance changing her/his clothing, Resident #1 did not receive assistance changing clothing for approximately four hours.",2,,Not Substantiated,Substantiated, +BC150449,385031,NF,3/2/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to skin care and the development of coccyx ulceration. The facility failure to provide Resident #1 adequate care and services resulting in Resident #1 sustaining skin issues and a coccyx wound are violations of resident rights, are considered neglect of care and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000971000,385031,NF,5/20/2015,"Evidence and interviews indicated facility failure to ensure a care-planned alarm was activated for Resident #27 who sustained a fall, placing Resident #27 at increased risk for falls. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +BC152353,385031,NF,7/18/2015,Evidence and interviews indicated facility failure to assure Resident #1's rights related to circumstances where RP2 (CNA) likely was inconsiderate and disrespectful while assisting Resident #1 with care needs. Facility terminated RP2's employment on 8/31/2015.,2,,Not Substantiated,Substantiated, +OR0001022301,385031,NF,10/28/2015,"Evidence and interviews indicated facility failure to ensure CBG orders were followed for Resident #1 and Resident #5. In addition, evidence and interviews indicated facility failure to ensure Resident #1 and Resident #8 were provided wound care per physician orders. These failures placed residents at risk for unnecessary procedures and delayed wound healing; relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001022302,385031,NF,10/28/2015,Evidence and interviews indicated facility failure to develop a comprehensive care plan for Resident #1's colostomy and Foley catheter care and services. This failure placed Resident #1 at risk for lack of Foley catheter and colostomy care services; relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001055400,385031,NF,1/25/2016,"Evidence and interviews indicated facility failure to complete an investigation within five days of Resident #1_x001A_s fall on or about 7/22/2015 placing Resident #1 at risk for neglect of care. In addition, evidence and interviews indicated facility failure to provide neurological assessments for Resident #2 who sustained a fall from her/his wheelchair on or about 1/23/2016 and Resident #3 who sustained a fall from bed on or about 1/26/2016. In addition, evidence and interviews indicated facility failure to implement a tab alarm per physician orders for Resident #3. The failure to provide a safe environment including adequate assessments and interventions placed Resident #2 and Resident #3 at risk for falls and unidentified injuries. In addition, evidence and interviews indicated facility failure to ensure residents had fall mats and wheel chair trays in place according to care plans for Resident #3, Resident #5 and Resident #6. The failure to ensure care planned interventions for falls were implemented placed residents at risk for injuries. Relevant portions of the complaint report investigation are attached.",3,1000,Not Substantiated,Substantiated, +NB105109,385039,NF,8/16/2010,"Staff reported placing RV in a wheel chair at the nurses station with an alarm in place. Staff (W1) observed RV stand up and fall before W1 could intervene. Staff found the alarm was not plugged in, but reviewer notes this would not have made a difference in RV's non-injury fall as staff observed the event. Staff failed to ensure all resident equipment was functioning appropriately and in place as care planned.",2,0,Not Substantiated,Substantiated, +NB103809,385039,NF,3/20/2010,"Staff and W1 reported staff rotation around the facility resulting in staff dependence on resident care plans. W4 reported RV_x001A_s care plan was not updated. RV did not receive all necessary care and services regarding bed rail use, use of pillows, use of a transfer pole and /or consistent RA. Additionally, the facility has failed to reassess, care plan; correctly and/or consistently apply RV_x001A_s arm brace resulting in continued sporadic bruising of RV_x001A_s left arm. RV requested toileting and was made to wait for toileting. The facility failed to provide all care and services resulting in actual harm and/or potential for harm.",3,200,Substantiated,Substantiated,Neglect +NB105145A,385039,NF,8/31/2010,RP2 refused to tell RV what medication RP2 was giving to RV. RP2 reported the list of medications were at RV's bedside. RP2 failed to follow RV's care plan and tell RV what medication RV was receiving. RP2 failed to honor RV's request for RP2 to recite the medication RP2 was giving. Staff left the room without giving the medication and then returned later to dispense the medication with other staff present.,2,0,Not Substantiated,Substantiated, +NB092969,385039,NF,12/23/2009,"RV fell out of bed without signs of bruising, but RV did complain of his/her head hurting. RV complained of nausea and RV was sent for evaluation/placement of his/her feeding tube. RV waited for assistance with toileting due to a two person staff assist. RV was admitted with skin break down and care planned for two hour repositioning. Despite repositioning not always being provided/documented, RV's skin break down as been reduced. RV was at risk for further harm due to facility failure to provide all care planned services.",2,0,Substantiated,Substantiated,Neglect +NB116311,385039,NF,2/8/2011,RV did not receive adequate hygiene care resulting in dried BM on his/her person and under garments. RV was found with dried sloughing skin on his/her feet and dirty socks. There is no documentation of hygiene care the day prior or day of discharge. A reasonable person would find the significant lack of hygiene as a serious loss of dignity.,2,0,Substantiated,Substantiated,Neglect +NB103087,385039,NF,12/14/2009,"Evidence provided in this investigation reported indicated all shower care was not provided and or documented. Evidence is inconclusive for RV's wounds worsening due to lack of care, but RV was at risk for harm.",2,0,Not Substantiated,Substantiated, +NB116124,385039,NF,1/13/2011,"No baths were recorded for RV, but RV and linens were clean and without odor per direct investigator observation. The facility failed at minimum to document bathing RV and at maximum failed to provide baths. Evidence was not presented indicating RV had sustained any notable harm. RV was at risk for potential skin issues without sufficient bathing.",2,0,Not Substantiated,Substantiated, +NB116308,385039,NF,2/5/2011,"RV reported, as well as, witnesses that RP2 attempted to give RV incorrect medication. RV refused to allow RP2 to check the medication against the orders and kept the medication RV was not given his/her medication with in the allowed standard of time.",2,0,Not Substantiated,Substantiated, +NB117241,385039,NF,5/23/2011,"On 5/23/11 the complainant shared many concerns including staff failure to assist RV to use the commode, falls, improper care and failure to dispense medications. W1 and W2 added complaints of RV being left in a soaked bed and being refused water. RV reported being ill/vomited on 5/21/11 and staff did not clean him/her before the EMTs arrived. RV reported staff were slow in response to his/her call light and RV was left in a soaked bed once. Staff failed to dispense medication or failed to properly document why medication was not given on certain days. Reviewer notes the same days could be linked to the time frames of RV's nausea/vomiting. There are other failures or documentation failures to provide care, i.e.. Weights, PICC Flushes and blood pressure readings. The facility failed to provide all care plan and or physician ordered care. RV was at risk for harm.",2,0,Not Substantiated,Substantiated, +NB118440A,385039,NF,11/1/2011,"RP2 repeatedly failed to follow physician order to change RV's dressing on RV's wound. There was no noted change in RV's wound. RP2 failed to circle the treatment orders and or write on the treatment sheet why the dressing was not changed. RP3 admitted failing to change the dressing on 11/3/11. Other treatment on 10/27/11 was not initialed. Evidence does not support a negative effect to RV, but all staff should provide treatment as ordered and properly document treatment that is given. Further staff in-service was provided.",2,0,Not Substantiated,Substantiated, +NB118440B,385039,NF,11/1/2011,"Witnesses identified specific protocol in dispensing PRN narcotics. Witnesses reported sloppy documentation regarding time and dispensing of narcotics. Residents receiving medication and with the ability to give relevant information reported either no concerns or they are receiving medication. Evidence does not support negative effect to residents, but all staff should be properly documenting medication given to residents.",2,0,Not Substantiated,Substantiated, +NB118633,385039,NF,12/2/2011,"RV's call light was not canceled for over 70 minutes on 12/2/11. RV became distressed when the call light was not answered in a timely manner per W4. W5 was in RV's room at various times prior to the call light being cancelled. W5 reported spending time with RV and the need to obtain physician orders regarding over the counter medication that RV was requesting. While RV was later transferred to the hospital for evaluation, evidence is insufficient to link the less than stellar response to RV's call light as the reason RV was sent for further evaluation.",2,0,Not Substantiated,Substantiated, +NB129115A,385039,NF,1/15/2012,"RV resided at the facility from 2/7/2011 to 3/4/2011. RV, W2, W3 and W5 reported RV did not receive ordered medication consistently and or timely. RV transferred to the facility on 2/7/2012 and medication was not available until noon on 2/8/2012. RV's prescribed antifungal cream was not consistently given and or documented as given. RV reported having seizure/tremor activity related to not receiving medication on time. W1 and W6 were not familiar with RV's care the year prior to the complaint being made. Record review does reveal nursing notes showing family concerns and the facility addressing the concerns. The facility failure resulted in a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +NB129003,385039,NF,1/19/2012,"RV was admitted 1/14/2012 following a fall with fracture and surgical intervention. RV reported his/her bandage was not changed for 7 days, but then reported it was changed by W4 on 1/29/2012. W1 reported based record review physician orders were not followed. W4 reported the wound looked good and was healing. Facility staff either failed to change the dressing as ordered or failed to document care. Staff received further in-service and training. The facility failure is a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +OR0000737700,385039,NF,12/30/2011,RP2 admitted turning Resident 1's pressure alarm off; stating Resident 1 was asleep at the time and every time when responding to the alarm Resident 1 was in the same position. Staff found Resident 1 on the floor; resident reported attempting to use the urinal and sliding off the bed. Resident 1 was not injured. The facility violated a Oregon Administrative Rule. Relevant portions of the survey are attached. Enforcement action was recommended. All staff will be in-serviced on following resident plan of care; specifically use of alarms.,2,0,Not Substantiated,Substantiated, +NB118756,385039,NF,12/22/2011,"W1 and W2 voiced concerns regarding RV's bathing, colostomy bag care and pain medication. RV would refuse bathing and personal care at times. Record review indicated not all medications and or treatments were appropriately documented. Documentation indicated RV was not offered a shower two times per week as caare planned. Facility failure to provide and offer care on a consistent basis represents a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +NB120079,385039,NF,5/8/2012,"RP2 told RV1 to be ""quiet and or don't interrupt me"" per RV1 and other witnesses. RV1 reported RP2 told them to ""shut up"", but this was not what W5 over heard. RP2 asked RV3 if he/she wanted to pray and RV3 reported being upset and RP2 ""kept going on and on with RV3 telling RP2 to go away."" RP2 failed to treat RVs with all due respect. The facility failed to report the suspected abuse or investigate the allegations in a timely manner. This facility failure presents as an Oregon Administrative rule violation.",2,0,Not Substantiated,Substantiated, +NB129837,385039,NF,4/10/2012,"The facility failed to ensure an adequate system was in place and or followed by staff to prevent theft of resident medication; and ensure all residents received pain medication as ordered. The attached report referenced RV1 through RV23 as having narcotic medication taken directly from their personal medication card/liquids or medication taken from the Emergency Medication Dispensing (EMD) machine and signed out to a particular resident resulting in the resident being charged for the medication. RP2 accessed the EMD machine in particular for RV1 and RV2 when they had their own narcotic medication available. Witnesses reported multiple errors by RP2 in medication record documentation and CAOs for the EMD machine from 1/25/2012 through 4/10/2012. RP2 received two cards of narcotics for RV1 on 4/11/2012, but failed to document a missing card of 30 tablets. RV1 denied receiving 4 pain pills at a time, was in severe pain and went to the hospital. W6 reported concerns regarding RP2 ""several times"" to administration. RP2 admitted to improper documentation and use of resident medication for personal use which constitutes theft and abuse. The facility failure to ensure resident medications were safe; ensure residents received pain medication as ordered; and promptly investigate medication discrepancies constitutes abuse by neglect and represents an Oregon Administrative Rule violation.",3,450,Substantiated,Substantiated,Financial abuse +NB120862,385039,NF,8/17/2012,RV1 and RV2's family reported missing money. RV1 reported not using his/her locking drawer; has no key. RV1 reported living at the facility several years without prior incident. RV2's family reported RV2 had specific monies RV2 kept for sentimental reasons. Facility staff immediately reported the missing monies to law enforcement and APS. Police investigation N2o123277 had no resolution. The facility failed to ensure RV1 had a key for his/her locking drawer or ensure RV2's possessions/money was safe. The facility failure resulted in multiple thefts of money which constitutes abuse and a Oregon Administrative Rule violation.,2,200,Substantiated,Substantiated,Financial abuse +OR0000785000,385039,NF,9/24/2012,"Resident 1 was admitted March 2012 with multiple diagnoses including Alzheimer's and assessed fall risk. Resident's care plan included use of a bed and wheel chair alarm. On 9/15/2012 resident crawled out of bed, attempted to get in his/her wheel chair. Staff found the resident on the floor and he/she was uninjured. Staff 2 revealed forgetting and failing to attach the alarm, but staff was alerted and immediately placed the alarm. The use of the alarm is being re-evaluating. An Oregon Administrative Rule violation occurred.",0,0,Not Substantiated,Substantiated, +NB121148,385039,NF,9/18/2012,"RV reported an unknown care giver caused a bruised arm during assistance with dressing. RV reported feeling safe and is relatively happy at the facility. W3 reviewed nursing notes and found no documentation of the bruise or abrasion. W1 thought the wound location was consistent with RV bumping his/her arm. W2 suspected the wound occurred if RV's arm fell from the wheel chair and caught in the wheel chair brace. The 9/8/2012 nursing overview did not indicate the skin injury, but the 9/21/2012 revealed documentation of the injury. W5 failed to fill out the ADL for 9/20/2012. Skin assessment sheets of 9/18/ and 9/22/2012 document bruising and a scab. The origin of RV's skin injury remains unknown. The facility failed to ensure proper documentation of care and the injury. The failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +NB132571,385039,NF,3/6/2013,"The facility failed to ensure RP2 completed and or documented blood pressures on RV1 through RV12 prior to administering anti-hypertensive medication. The facility failure continued multiple days for multiple residents January and February 2013 placing the residents at risk for harm. RP2 attended and signed documentation for a December 2012 in-service regarding completion of blood pressures prior to administering anti-hypertensive medication. RP2 reported feeling stressed, but RP2 did not report not being able to complete required tasks. Oregon Administrative Rules were violated.",2,200,Not Substantiated,Substantiated, +OR0000809300,385039,NF,2/4/2013,"Resident 1 was admitted January 2013 with multiple diagnoses including a stroke and bradycardia. Resident had a recorded temperature of 85.8 degrees F on 1/26/2013, but no indication staff notified resident's physician or provided intervention for the low temperature. The resident's temperature was not recorded again until 1/28/2013 (temperature was 95.2 F) and not recorded again until 1/31/2013 when the temperature was recorded twice at 85 degrees F. The resident's Nursing Progress notes of 1/28/2013 indicated resident's increased weakness and W3 (Medical Director) was notified and W5 (PA) progress note indicated W5 notified W3. W3 reported being concerned about resident's bradycardia and that he told a facility nurse (no indication which staff nurse) the resident needed ""warming measures"". W3 indicated telling W4 (PCP) of resident's 85.5 temperature, but did not feel the resident needed to go to the ER. Staff deny the temperature was in the nursing progress notes, but staff ( in particular Staff 2) agreed the facility failed to address resident's low temperature timely January 2013. relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +NB133233A,385039,NF,5/15/2013,"Staff failed to change RV's leaking colostomy bag, clean RV and failed to change RV's soiled linens in a timely manner. W3 reported RV had been left without a colostomy bag for at least 2 to 3 hours. RV confirmed staff failure to promptly provide RV with colostomy care and left RV soiled. Staff failure to provide care resulted in a significant dignity issue and constitutes neglect of care and abuse. An Oregon Administrative Rule violation occurred.",3,400,Substantiated,Substantiated,Neglect +NB133325,385039,NF,5/16/2013,Multiple residents and staff report lack of staff to answer call lights timely; failure to provide showers and care as care planned; failure to provide PRN pain medication in a timely manner resulting in continued pain; and provide requested assistance in general. RV1 reported his/her physical therapy is suffering because he/she cannot walk as needed. RV6 reported it takes a long time to get PRN medication and RV7 reported being in pain due to staff failure to change the pain patch timely. RV12 reported failure to receive insulin in a timely manner; this would place RV at risk for harm. Hand written staff notes for 5/28/13 and 6/3/2013 indicate short staffing contributed to a resident fall and residents soaked in urine. The facility failure to provide adequate care and services resulted in neglect of care and resident harm which constitutes abuse. An Oregon Administrative Rule violation occurred.,3,500,Substantiated,Substantiated,Neglect +OR0000822800,385039,NF,4/9/2013,"Staff 9 repeatedly transferred residents without using a gait belt as discussed resident care plan and or facility policy. Staff 9 transferred Resident 5 without using a gait belt, was unable to support the resident well, resident dropped to the floor and sustained a skin tear. The facility failed to ensure all staff follow resident care plans and or follow facility policy/procedure a safe resident environment. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +OR0000827500,385039,NF,5/2/2013,"Resident 1 was admitted 12/2010 with multiple diagnoses including a history of falls and delirium. Resident care plan of 1/10/2013 indicated one person assist with transfers using a gait belt. On 4/20/2013 Staff 1 and 2 transferred resident without using a gait belt, resident's knees ""gave out and staff lowered the resident to the floor. The resident sustained an fractured knee. Staff 2 reported the other CNA failed to use a gait belt. Staff reported not knowing why the gait belt was not used. Staff received written/oral warnings. Relevant portions of the survey are attached. Enforcement was proposed. An Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +NB133739,385039,NF,7/3/2013,RV received tube feedings at times later than ordered. Staff failed to document fluids and supplements for RV. The resident was at risk for harm. The facility failed to provide all appropriate care for RV. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000843700,385039,NF,8/7/2013,"Resident 1 was admitted with diagnoses including impaired cognition, intrusive wandering, etc. Witnesses observed resident wander in the hallways while using a wheel chair shortly before the resident was found down the stairwell with head injuries and a pelvic fracture. The exit doors to the stairwell were not secure and allowed the resident to enter the stairwell. The facility provided magnetic locks and other safety measure following the event. The resident was a new admission and Staff 24 was not given information that the resident required close supervision. The facility failed to provide an environment free from accidents or environmental hazards. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000843701,385039,NF,8/7/2013,"Resident 1 was admitted with diagnoses including impaired cognition, intrusive wandering, etc. Witnesses observed resident wander in the hallways while using a wheel chair shortly before the resident was found down the stairwell with head injuries and a pelvic fracture. The exit doors to the stairwell were not secure and allowed the resident to enter the stairwell. The facility failed to adequately care plan for resident safety. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +NB134190,385039,NF,8/18/2013,"The facility failed to ensure RV received adequate incontinence care resulting in RV wearing urine soaked briefs. RV did not receive all care planned baths. While RV refused care at times, documentation was not sufficient to support RV refusing care. RV did not sustain skin changes. The neglect of incontinence care resulted in a significant loss dignity which constitutes abuse. An Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +OR0000854400,385039,NF,9/24/2013,"Resident had lived at the facility since 2011 and documentation indicated the resident had multiple diagnoses including cognitive impairment, weakness, osteoporosis, etc. On 9/21/2013 resident was found with some facial bruises and other injury. Resident care plan noted agitation and assistance of one person with transfers with noted interventions. Staff 6 and 5 reported assisting the resident off the floor and or into bed after Staff 7 told Staff 6 that he/she (Staff 7) had assisted the resident to the floor. Staff 6 stated Staff 7 told Staff 6 there was not a need for an incident report. Staff 5 reported Staff 7 stated the resident was ok after Staff 5 reported observing resident bruising. Staff from night shift also reported concerns to Staff 7 and Staff 7 indicated no knowledge that bruising occurred. Ob 9/22/2013 facility staff found resident injury, but failed to thoroughly investigate or report the findings. Staff 7 denied any knowledge of resident injury or fall as of 9/23/2013. the facility failed to ensure resident safety constitutes neglect and abuse. Enforcement action was recommended. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +OR0000846501,385039,NF,8/19/2013,Resident 2's physician orders of 6/27/2013 indicate staff were to offer 120 cc nectar thick fluids every two hours and document what the resident consumed. Staff failed to properly transcribe the order to the July MAR. The resident was at risk for dehydration. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +NB134875,385039,NF,10/2/2013,"RP2 left RV alone in the shower as care planned, but failed to stay outside the shower as care planned. RP2 reported telling staff that RP was going on break, but denied staff said to stay. Staff 2 and 5 reported they were assisting another resident with a shower and told RP2 to stay, but RP2 did not and they alerted W4 with other staff coming to assist. RV did not sustain harm and was still showering when RP2 returned. An Oregon Administrative Rule was violated.",2,,Not Substantiated,Substantiated, +NB135020,385039,NF,11/8/2013,"The complainant and W2 reported RV is not receiving proper care, i.e.. Leaving RV on a bed pan for 90 minutes, leaving RV in a wheel chair for 1 to 2 hours and not offering RV food with medication. RV reported inability to reach and use the call light and waiting at least 20 minutes for assistance. RV reported receiving pills at 9:00 P.M., but not usually receiving medication at that time and threw up as receiving pills without food. RV did not have a physician order to receive medication with food, but RV prefers this. RV now has a night time snack and medication times have been changed. RV has not evidence of a ""sore bottom"". The call light log reveals the longest time RV's light was on was 24 minutes.",2,,Not Substantiated,Substantiated, +NB134853,385039,NF,10/24/2013,RV's wallet went missing with possible unknown amount of money. RV has a history of hiding belongings. RV has a new wallet that is now locked in the facility safe. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Financial abuse +OR0000860800,385039,NF,10/30/2013,"Resident 1 was admitted 2013 with documentation of 9/30/2013 revealing the resident had a red coccyx. Resident admission assessment and interim care plan indicated pressure ulcer risk. The interim care plan dated 9/302013 did not mention the red coccyx area, but included weekly skin checks. No documentation was found to indicate skin checks were completed. A 10/7/2013 MDS did not indicate pressure ulcers. The 10/8 2013 nutritional assessment did not include interventions. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +NB145877,385039,NF,1/20/2014,Preponderance of evidence found RP2 failed to take RV1 and RV2's vital signs in a timely and or accurate manner. RV's were at risk for harm. W2 did obtain RV1 and RV2's vital signs later in the day.,2,,Not Substantiated,Substantiated, +OR0000870600,385039,NF,1/6/2014,"Resident 1 was admitted October 2013 with diagnoses including seizure disorder. Resident's 12/15/2013 care plan provided interventions for fall risk. On 1/5/2013 resident ended up on the floor during a transfer, but was not injured. Staff 3 reported the bed mattress slid side ways and the slide board bumped the wheel chair brake resulting in the wheel chair moving the opposite direction. Resident care plan was updated 1/9/2014. there was a complaint that the wheel chair brake handle was broken at the time of the event, but the handle was not fixed by 2/25/2014 direct survey observation. Failure to timely repair the brake handle placed the resident at risk for further falls. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000870601,385039,NF,1/6/2014,"Resident 1 was admitted October 2013 with diagnoses including hypertension. Resident vital signs including blood pressure were not timely monitored and or documented beginning 1/13/2013 with a noted blood pressure of 78/48. While the resident's physician was faxed, there was insufficient follow up. Additionally the resident's physician appointment was rescheduled and again the facility failed to promptly notify the physician of the fluctuating blood pressure; only noted it in the the packet the resident would take to the rescheduled appointment. The resident was found unresponsive on 1/14/2014 at 9:21 A.M., physician notified and resident transferred to the hospital. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +NB146366,385039,NF,10/1/2013,"The facility discovered and reported missing narcotic documentation, as well as, actual missing narcotics from October 2013 to the beginning of March 2014. The facility discovery occurred after a change in facility administrative staff. The facility investigation noted RP2 was on duty when narcotic medication errors and discrepancies occurred. RP2 had requested a demotion in duty, worked night shift when there is less supervision; and passed medication at the time the medication and documentation went missing. Narcotic record review indicated RP2 gave more narcotic medication to residents who normally did not request medication when other staff were on duty. Additionally, medication is missing for residents without a record of destruction. Evidence is inconclusive for physical harm to residents, but preponderance of evidence substantiates theft of resident medication occurring over an extended period of time. The facility failed to provide timely oversight and intervention regarding theft of medication. This failure constitutes abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Financial abuse +NB146593,385039,NF,4/1/2014,"The complainant voiced multiple concerns regarding RV1 and made a reference to RV2. Both RV1 and RV2 were sent to the hospital on 3/30/2014 with a change of condition. W7 reported staff failure to turn RV1 every two hours, left RV1 naked in bed without a blanket and failed to call the physician timely regarding RV1's change of condition on 3/30/2014. RV1's hospital record indicated opiates in RV1's urine, but RV1 MAR does not indicated RV received any opiates. The origin of opiates in RV1's urine remains unknown. The facility failed to ensure a safe environment resulting in RV1 receiving opiates and constitutes abuse. + +Documentation review found RV2 received medication as ordered, but not all documentation was completed regarding RV2's blood pressure. Documentation review found RV2 was assessed to use bilateral hearing aids, but quantity was not listed. W1 reported loss of a hearing aid at the facility leaving RV2 without any hearing aids and or the ability to adequately understand anyone speaking to RV2. Social Services must assist residents in obtaining needed prosthetics, but RV2 did not have hearing aids when the investigator spoke to RV2 on 4/4/2014 resulting in difficult communication with RV. . Oregon Administrative rule violations occurred.",3,800,Substantiated,Substantiated,Neglect +OR0000894700,385039,NF,5/6/2014,Resident 5 was admitted 4/25/2014 with diagnoses including a total hip replacement. The resident did not receive Fentanyl patches as ordered. The resident's pain was well controlled by the hydrocodone medication as staff reported. Staff failed to clarify the hydrocodone orders/doses). Relevant survey pages are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +CO15169,385039,NF,8/20/2015,Facility chose to apply a voluntary restriction of admissions.,2,0,Not Substantiated,Substantiated, +OR0000950700,385039,NF,2/25/2015,Resident 2 was admitted January 2015 with diagnoses including a stroke. Per witness interview and documentation review the facility failed to provide the resident the right to participate in his/her care plan development including resident concerns regarding call light response and the resident's fall of 2/19/2015/ it was determined the facility staffing was insufficient to respond to resident's needs; in particular failure to promptly respond to the resident's call light on 2/19/2015. Failure to respond promptly resulted in neglect of resident's needs which constitutes abuse. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0000971400,385039,NF,5/21/2015,"Resident 3 was admitted February 2015 with diagnoses including stroke; resident was discharged 5/19/2015. Bbased on interview and record review it was determined the facility failed to assess the resident's change of condition and failed to follow all physician orders. A weekly wound note of 4/20/2015 indicated skin impairment to the right great toe and treatment provided. Resident progress notes from 4/26/15 through to 5/19/2015 indicate treatment to the right toe/foot was listed on the discharge instruction form. The facility failed to ensure physician orders for home health were implemented. The resident was at risk for harm. Interview and record review indicate Resident 3 indicate an abrasion to the right ankle, but no measurements were taken. There were further skin assessment after 2/18/2015, but the facility 2010 policy and procedure was not implemented as identified in the policy procedure. Additionally the facility failed to insure sufficient staffing to provide for resident needs; in particular there were three missed showers 4/18/2015 because the facility was ""short staffed"". Relevant portions of the survey are attached.. Enforcement action was proposed. There were Oregon Administrative Rule Violations.",2,,Not Substantiated,Substantiated, +OR0000978800,385039,NF,7/1/2015,"Resident 2 was admitted to the facility 6/25/2015 with diagnoses including a stroke. From 6/26/2015 until hospital admission of 6/28/2015 the resident sustained a changing condition including diarrhea, lethargy, nausea and vomiting. The facility staff failed to notify the resident's family in a timely manner regarding the resident's change of condition and the initiation of Zofran. Staff failed to document and assess the resident's bowel changes, behaviors and food/fluid change after 6/26/2015. relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000978801,385039,NF,7/1/2015,The facility failed to ensure sufficient nursing assistant staffing to provide for resident's needs for 5 of 7 sampled residents. Per interview and documentation review there were numerous shifts without adequate or minimal levels of staff resulting in resident needs not being met. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred. This reviewer notes prior facility history of monetary sanctions being given to the facility during the last three quarters for less than minimum staffing levels being met.,2,,Not Substantiated,Substantiated, +OR0001032100,385039,NF,11/23/2015,Resident 1 was admitted 11/19/2015 with diagnoses including chronic lung disease. Resident's Hospital Transfer orders included no activity restriction for walking and a Physical Therapy (PT) evaluation. The resident's admission assessment identified staff assistance for transfers and walking; resident with a high fall risk. The resident's bed side care plan identified the resident's fall risk and provided interventions. Staff observed the resident thirty minutes prior to finding the resident on the floor with noted injury. The facility did not fail to provide care and services for Resident 1's safety. Two additional residents were reviewed. Resident 3's care plan was not updated to include use of a non skid pad the resident used. The resident was at risk for another fall. Relevant survey pages are attached. Enforcement was proposed. An Oregon Administrative Rule violation occurred..,2,,Not Substantiated,Substantiated, +NB153655,385039,NF,11/19/2015,RP2 cut one of RV2's medication in half and gave the half to RV1. RP2 reported RV1's medication had not arrived from the pharmacy. RP2 told W1 and a surveyor what RP2 did. Neither RV1 or RV2 were harmed by the event. RP2 refused to communicate with the facility and resigned from employment. RP2 left a voicemail with the information that he/she was moving. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +CO16029,385039,NF,2/16/2016,Continued failure to provide appropriate staffing with an increased risk of harm.,3,0,Not Substantiated,Substantiated, +NB164701,385039,NF,2/18/2016,"The facility failed to ensure RV's choice for care was not secure, family was not informed of the earlier time for the care conference and came in later. RV reported threat of jail by multiple staff and in particular RP3 and became teary and upset . Witnesses report RV is now not accepting bed baths due to fear of pain, making a fist or making a comment; RV is afraid if RV makes a fist or yells RV will be arrested. RV denies making a racial slur, but admitted to throwing the telephone on the floor. RV reported an incident report would be filled out and given to RV, RV denied being given the incident report. RP3 did not fill out an incident report regarding the racial slur or RV trying to hit staff. Acknowledged telling RV that if RV hits staff police would be called and reported RV was ""upset"" with being moved to the first floor. Staff failed to fully assess and provide intervention for RV's behaviors of calling staff names and or throwing objects; and RV's "" being upset"" with the move to the first floor prior to the 2/18/2016 event. The facility failed to fully respect and treat RV with dignity resulting in a significant loss of dignity and feeling RV will be arrested. This neglect of care constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000660800,385044,NF,1/12/2011,"Resident 1 was admitted July 2010 with diagnoses including chronic renal failure and as stroke. The 8/4/10 RD assessed fluid goal was 1950 cc a day, but the intake and output record form 12/23/10 through 1/5/11 showed 1017 cc at most. Staff reported Resident 1's fluid intake was not addressed by the nutritional committed and the care plan was not updated. Additionally Resident 1 developed a UTI on 12/19/10 without further care plan intervention to provide proper hydration. Staff failed to ensure Resident 1 received sufficient hydration to meet the RD's fluid goals, failed to identify and address the resident's poor meal consumption or offer adequate replacement, etc. The facility completed a plan of correction.",2,0,Not Substantiated,Substantiated, +OR0000670500,385044,NF,2/22/2011,"Resident 1 was admitted to the facility on 1/19/11 with diagnoses including cellulitis, and had physician orders for Vancomycin 1.25 gm to be given in 150ml of saline through a PICC line every twelve hours. Staff 3 (RN) gave Resident 1 the 1 gm of Vancomycin in 5 ml of saline instead of 150 ml as ordered, and administered it ""IV push"" (bolus) instead of the standard administration procedure using an intravenous bag to provide the medication over time. Resident 1 informed Staff 3 not to give the Vancomycin as he/she was administering the medication, and requested the physician be contacted. Resident 1 complained of arm ""tingling"" and not feeling well. Resident 1's physician was contacted and she/he was sent to the ER due to risk of shock and organ failure. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000680300,385044,NF,4/5/2011,"Resident 3, a long time resident, was admitted with diagnoses including infantile cerebral palsy. Resident 3's 3/17/11 MDS revealed extensive assistance with dressing. Nursing notes of 3/11 at 1:01 revealed a CNA assisted Resident 3 to remove his/her coat and a ""pop"" was heard. Resident 3 sustained a right humurous fracture. Review of Resident 3's April 2011 ADL and in room care plan did not reveal information regarding Resident 3's ROM, contractures or what assistance was required for dressing other than dressing with assistance. Staff did not receive adequate instruction regarding Resident 3's contractures and needed assistance with dressing resulting in Resident sustaining a right arm fracture. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000681600,385044,NF,4/11/2011,"Resident 1 was admitted with diagnoses including seizures, stroke and diabetes. Resident 1 was assessed as alert, oriented and able to answer questions. Resident 2 reported Resident 1 attacked him/her on 4/10/11. Resident 1 had previously refused his/her medication and was known o seizure. Resident 1 did not recall the attack or the seizure. Resident 1 and Resident 2 were place din separate rooms. Resident 1' care plan was not up dated following these events. Resident 1's in room care plan did not address sign/symptoms of hypoglycemia or risk for hypoglycemia. Staff did not ask Resident 1 if she/he would take his/her anti-seizure medication in anything else when he/she refused the medication in apple sauce. Staff 4 (CMA) had asked a charge nurse, but received no other instructions. There is no evidence Resident 1's physician was contacted regarding the 4/12/11 physician order to place the seizure medication in food. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +BC117303,385044,NF,6/23/2011,"RV used a lockable drawer in his/her room and had the only key. RV reported $1000.00 was in the drawer two weeks before he/she noticed it missing. RV reported staff had suggested he/she keep the money with the facility book keeper, but RV refused. RV reported giving very small sums money to other residents. Staff deny knowledge in regards to the missing money. There was no sign of forced entry into the locked drawer or who may have taken the money; possibly another resident.",2,0,Substantiated,Substantiated,Financial abuse +OR0000705802,385044,NF,8/8/2011,Resident 1 was re-admitted 7/14/11 with multiple diagnoses; and the hospital transfer sheet identified that Resident 1 would pocket food and was at risk for aspiration. Resident 1's care plan did not reflect Resident 1's aspiration risk and staff were not aware of the aspiration risk or interventions until 7/18/11. Relevant portions of the survey are attached. Enforcement action was recommended..,2,0,Not Substantiated,Substantiated, +OR0000733100,385044,NF,12/6/2011,Resident 1 was admitted 11/4/2011 with multiple diagnoses. Resident 1's physician orders included Coumadin 2 mg daily and Lovenox 120 mg every 12 hours for 5 days. Between 11/7/2011 evening shift and 11/30/2011 day shift Resident 1 received 41 Lovenox injections in error. It is noted in the 2011 Nursing Drug Hand Book that Lovenox given with Coumadin usually is given for 5 to 7 days until the INR is at a 2 to 3. staff 2 stated the Lovenox error occurred because she failed to write the stop date when re-writing the orders. Other staff and the pharmacy failed to catch the potential for harm/error. Resident 1 required hospitalization to remove blood from Resident 1's right thigh; possibly related to resident's medication. All nurses received in-service update on facility policy. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000733300,385044,NF,12/6/2011,"Resident 2 was admitted to the facility 9/30/2011 with multiple diagnoses and physician orders for Cymbalta 120 mg per day. During a 10-20-2011 physician medication review meeting there was a request to change the time Resident 2 received the Cymbalta, but nothing regarding the dosage although the Nursing Drug Handbook indicated a maximum dose of 60 mg per day. Resident 2's A.M. dose was not discontinued and Resident 2 received 120 mg A.M. and P.M. from 10-21-2011 to 11-6-2011. The facility notified Resident 2's physician on the medication error after Resident 2 questioned the dosage. At the time of the investigation Resident 2 denied any negative outcome due to the medication error. The facility failed to ensure appropriate medication review. Resident 2 was at risk for harm. Relevant portions of the survey are attached. Enforcement action was recommended.",2,0,Not Substantiated,Substantiated, +BC128904B,385044,NF,1/5/2012,"W1, complainant 2, W2, W6, W8, etc. reported a less than stellar discharge plan. The confusion resulted in a delay of home health and wound care. The facility failure represents a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +OR0000762000,385044,NF,5/15/2012,Resident 1 was admitted February 2012 with diagnoses including dementia and a left shoulder fracture. Resident was care planned at risk for falls with interventions including a tab alarm in bed and in the wheel chair. The nursing assessment of 5/11 & 5/12/2012 identified the resident continued to climb out of the wheel chair. On 5/13/2012 resident sustained an witnessed fall by the nurses station. Staff 1 reported the alarm was effective if the resident was near staff. Staff were not near enough to the resident at the time of the fall and the alarm was not in place. Resident 1 was evaluated at the hospital and no injury was found. Relevant portions of the survey are attached. Enforcement action was proposed. The facility failure represents an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +OR0000771700,385044,NF,7/13/2012,"Resident 1 was admitted March 2012 with multiple diagnoses including nausea, chronic pain, neuropathy, anxiety, depression and esophageal reflux. Later diagnoses included open wound to the right thigh and herpes. Based on observation, interview and record review it was determined the facility failed to follow physician orders, failed to obtain treatment orders for treatments used, complete wound assessment and tracking, address changes of condition timely and comprehensively assess increased complaints of pain. As a result, Resident 1's had increased complaints of pain that were not assessed and effectively managed and Resident1's skin breakdown worsened. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure is an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +OR0000771701,385044,NF,7/13/2012,"Resident 1 was admitted March 2012 with multiple diagnoses including nausea, chronic pain, neuropathy, anxiety, depression and esophageal reflux. Later diagnoses included open wound to the right thigh and herpes. Based on observation, interview and record review it was determined the facility failed to follow physician orders, failed to obtain treatment orders for treatments used, complete wound assessment and tracking, address changes of condition timely and comprehensively assess increased complaints of pain. As a result, Resident 1's had increased complaints of pain that were not assessed and effectively managed and Resident1's skin breakdown worsened. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure is an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +OR0000771702,385044,NF,7/13/2012,"Resident 1 was admitted March 2012 with multiple diagnoses including nausea, chronic pain, neuropathy, anxiety, depression and esophageal reflux. Later diagnoses included open wound to the right thigh and herpes. Based on observation, interview and record review it was determined the facility failed to follow physician orders, failed to obtain treatment orders for treatments used, complete wound assessment and tracking, address changes of condition timely and comprehensively assess increased complaints of pain. Additionally the facility failed to provide comprehensive bladder function assessment, catheter assessment and did not proved adequate care planning. Resident's physician ordered a catheter on 6/28/2012 without adequate nursing assessment or care planning. Relevant portions of the survey are attached. Enforcement action was proposed. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000771703,385044,NF,7/13/2012,"Resident 1 was admitted March 2012 with multiple diagnoses including nausea, chronic pain, neuropathy, anxiety, depression and esophageal reflux. Later diagnoses included open wound to the right thigh and herpes. Based on observation, interview and record review it was determined the facility failed to follow physician orders, failed to obtain treatment orders for treatments used, complete wound assessment and tracking, address changes of condition timely and comprehensively assess increased complaints of pain. Resident's 5/16/2012 pain care plan noted multiple interventions. A 6/27/2012 pain assessment indicated that at times resident's pain was ""horrible or excruciating"" without evidence of a comprehensive assessment and or change in the care plan. W1 reported requesting therapy screening regarding resident's pain for treatment other than loading up on narcotics. Resident 1 stated his/her pain was not managed and had worsened. Staff failed to properly follow up on the quarterly assessment. As a result, Resident 1's had increased complaints of pain that were not assessed and effectively managed. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure is an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +OR0000771704,385044,NF,7/13/2012,"Resident 1 was admitted March 2012 with multiple diagnoses including nausea, chronic pain, neuropathy, anxiety, depression and esophageal reflux. Later diagnoses included open wound to the right thigh and herpes. Based on observation, interview and record review it was determined the facility failed to follow physician orders; failed to obtain treatment orders for treatments used; complete wound assessment and tracking; address changes of condition timely; and comprehensively assess increased complaints of pain. Resident 1's 5/2012 Wound Assessment Flow Sheet disclosed an open lesion on the right inner thigh; 5/11/2012 staff received treatment orders which were followed, but there was no on going assessment or tracking of the genital herpes out break noted on 5/19/2012 or the discontinuation for Acyclovir ointment. The right thigh wound increased in size on 5/29/2012 and 6/5/2012 without treatment obtained until 6/13/2012. between 6/14/and 6/18/2012 no comprehensive documentation of assessment of the wound was found. On 6/18/2012 the physician was notified that the open inner thigh wound had not improved, treatment was changed, but not followed and no assessment for 7/10/2012 was found. Witnesses confirm missing treatment. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure is an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +OR0000771705,385044,NF,7/13/2012,"resident 1 was admitted March 2012 with multiple diagnoses including anxiety. On 7/8/2012 a progress note revealed Resident 1 was sent to the hospital after complaining of arm pain and stating pain "" due to CNA handling from precious NOC (night shift)."" The facility investigation failed to show evidence that residents and staff were interviewed. The facility failed to clearly define details or promptly report suspected abuse. Enforcement action was recommended. Relevant portions of he survey are attached. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000789700,385044,NF,10/18/2012,"Evidence and interviews indicated facility staff failed to ensure a care planned fall intervention for Resident #1 was implemented 10/13/2012. Resident #1 was found in her/his room at 3:15 pm lying on her/his right side on the floor, no visual injuries were found.",2,0,Not Substantiated,Substantiated, +BC133192,385044,NF,4/17/2013,Evidence and interviews indicated Resident #1 was not administered her/his medication according to physician orders. Evidence and interviews indicated Resident #2 was not administered medication as ordered.,2,400,Not Substantiated,Substantiated, +BC135038,385044,NF,11/7/2013,Evidence and interviews indicated Resident #1 was not timely administered PRN (as needed) narcotic pain medication according to physician orders. The Facility failure to timely administer Resident #1's PRN pain medications resulting in Resident #1 sustaining unreasonable discomfort is a violation of resident rights and is considered neglect of care.,2,300,Substantiated,Substantiated,Neglect +OR0000865001,385044,NF,11/27/2013,"Evidence and interviews indicated facility failure to update care planned interventions for Resident #1 to prevent injury. The Facility failure to implement interventions to prevent skin breakdown resulting in Resident #1 sustaining skin breakdown is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +BC147623,385044,NF,7/1/2014,"Evidence and interviews indicated facility failure to adequately monitor and assess Resident #1_x001A_s toenails and feet. Witness #4 said a podiatrist was seeing Resident #1 every three months, however the facility removed Resident #1 from the list for podiatrist services and the podiatrist had not seen Resident #1 since May 2011. + + + +On July 3, 2014, witness #3 asked to look at Resident #1_x001A_s feet and she/he said Resident #1 had a large, misshaped toenail that, _x001A_look infected._x001A_ Witness #3 said she/he told a licensed nurse at the facility that Resident #3 needed a podiatry appointment. Facility staff scheduled Resident #1 for a podiatry appointment on 7/22/2014. + + + +The Facility failure to adequately monitor and assess Resident #1_x001A_s toenails and feet resulting in Resident #1 sustaining fungal growth on her/his toes is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +BC148741B,385044,NF,9/17/2014,"Evidence and interviews indicated facility failure to ensure adequate medication administration for Resident #1. On 9/15/2014 Resident #1 requested a PRN (as needed) pain medication at 3 pm, however Resident #1 was not given the pain medication until 7 pm, placing Resident #1 at risk of pain.",2,,Not Substantiated,Substantiated, +BC149404,385044,NF,11/17/2014,"Evidence and interviews indicated facility failure to protect Resident #1 from financial exploitation resulting in the theft of Resident #1's money. On or about 11/07/2014 facility staff gave Resident #1 $30.00 of her/his Personal Incidental Funds (PIF) and Resident #1 placed $20.00 of the money in a small cabinet with a portable padlock in her/his room. On or about 11/11/2014 Resident #1 noticed the portable padlock was open and $20 was missing from the drawer. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining a loss of money is a violation of resident rights, considered financial exploitation, and constitutes abuse.",2,200,Substantiated,Substantiated,Financial abuse +BC150159,385044,NF,2/3/2015,"Evidence and interviews indicated facility failure to assure Resident #1's right to receive care and services from RP2 (licensed nurse) while being treated with consideration, respect and dignity. Facility failure to assure resident rights resulting in Resident #1 sustaining a loss of dignity is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000916100,385044,NF,8/14/2014,"Evidence and interviews indicated facility failure to provide adequate care and services related to monitoring mood and behaviors with Resident #1's active mental health diagnosis. The facility failure to provide Resident #1 adequate care and services related to monitoring mood and behaviors resulting in Resident #1 injuring her/himself in the chest with a knife and requiring hospital treatment are violations of resident rights, are considered neglect of care and constitutes abuse. Relevant portions of the complaint report are attached.",2,400,Substantiated,Substantiated,Neglect +OR0000919300,385044,NF,9/3/2014,Evidence and interviews indicated facility failure to provide adequate care and services related to monitoring mood and behaviors with Resident #2's active mental health diagnosis. The facility failure to provide Resident #2 adequate care and services related to monitoring mood and behaviors placed Resident #2 at risk for unnoticed decline in mood and/or escalated behavior. Relevant portions of the complaint report are attached.,2,,Not Substantiated,Substantiated, +OR0000926700,385044,NF,10/14/2014,"Evidence and interviews indicated facility failure to provide the necessary care and services related to Resident #3's falls on 7/23/2014, 9/16/2014 and 10/4/2014. The facility failure to interview potential witnesses and to thoroughly investigate incidents and accidents to rule out abuse and neglect related to Resident #3's falls placed Resident #3 at risk for abuse and/or neglect of care. Relevant portions of the complaint report investigation are attached.",3,600,Not Substantiated,Substantiated, +OR0000926701,385044,NF,10/14/2014,"Evidence and interviews indicated facility failure to notify Resident #3's family members after Resident #3's falls with injury on 7/23/2014, 9/16/2014 and 10/14/2014. This failure placed Resident #3 at risk for not having her/his rights upheld. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000969400,385044,NF,5/14/2015,"Evidence and interviews indicated facility failed to evaluate the need for bowel care and provide Resident #99 adequate care and services related to a change in Resident #99's medical condition. The facility failure to adequately evaluate and provide care and services related to Resident #99_x001A_s bowel care, resulting in Resident #99 requiring hospital treatment for a fecal impaction, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +BC152562,385044,NF,8/22/2015,"Evidence and interviews indicated Resident #1 was not timely administered medication including narcotic pain medication. From 8/1 through 8/12/2015 Resident #1_x001A_s scheduled pain medication was administered or charted as given more than one-hour late, on fifteen separate instances. In addition, medication administration records for Resident #1 indicated at least two separate instances on 8/4 and 8/7/2015 where Resident #1 was administered scheduled medication more than three hours after the scheduled dose times. The Facility failed to timely administer Resident #1_x001A_s PRN pain medication resulting in Resident #1 sustaining ongoing pain is a violation of resident rights and is considered neglect of care and constitutes abuse.",2,300,Substantiated,Substantiated,Neglect +BC152961,385044,NF,9/25/2015,"Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 who was admitted to the facility on 5/21/2015. Resident #1 was easily confused and was unable to locate her/his room in the facility. On 7/10/2015 Resident #1 was found at a fast food restaurant next door to the facility, she/he had removed her/his wander guard prior to leaving the facility unescorted. Afterward, this incident, the wander guard was placed underneath Resident #1's wheelchair. On 9/25/2015, facility staff reported Resident #1 as missing from the facility to local area law enforcement. On 10/14/2015 law, enforcement located Resident #1 in the community and returned her/him to the facility. Resident #1 was missing and gone from the facility for 19 days.",3,,Not Substantiated,Substantiated, +BC152703,385044,NF,9/1/2015,"Evidence and interviews indicated Resident #1 was not administered all ordered medications on 8/29 through 9/3/2015 because the medications were unavailable. In addition, Resident #2 did was not administered ordered medication on 8/28 and 9/4/2015. Medication administration records for Resident #3 indicated Resident #3 missed three doses of Ropinirole on 8/10 and 8/11/2015 because the medication was unavailable.",3,750,Not Substantiated,Substantiated, +OR0000977500,385044,NF,6/24/2015,"Evidence and interviews indicated facility failure to provide adequate care and treatment for resident changes in medical condition and failure to follow up with physicians in a timely manner, complete alert charting, follow physician orders, review/revise ineffective pain management program and assess and track wounds for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. Residents #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6 were at risk for continued decline in medical conditions and worsening skin breakdown. In addition, evidence and interviews indicated Resident #2 experienced prolonged, unaddressed pain. The facility failure to provide adequate care and treatment services for resident changes in medical condition, resulting in residents continued decline in medical condition and resulting in Resident #2 sustaining, prolonged unaddressed pain, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000980700,385044,NF,7/10/2015,"Evidence and interviews indicated facility failure to provide Resident #2 adequate wound care services resulting in Resident #2 experiencing prolonged, unaddressed pain. In addition, evidence and interviews indicated facility failure to obtain mental health services, assess refusals of care, monitor behaviors, and follow identified mental health interventions for Resident #2. Resident #2 did not receive mental health services when she/he exhibited an increase in depression and refused care services, which jeopardized her/his health. Evidence and interviews indicated facility failure to investigate causative factors for the development of pressure ulcers, contact the physician for treatment orders, follow physician orders for wound treatment and assessment, and track the wound treatment for Resident #5 and Resident #6. The facility failed to provide Resident #1, Resident #3, Resident #4, Resident #5 and Resident #6 adequate wound care and treatment services resulting in residents continued decline in medical condition and resulting. + + + +The facility failure to provide Resident #2 adequate wound care treatment and failure to provide adequate mental health services, resulting in Resident #2 sustaining prolonged unaddressed pain, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +BC154062,385044,NF,12/22/2015,"Evidence and interviews indicated RP2 (housekeeper) financially exploited Resident #1 on or about 12/22/2015 when taking approximately $640.00 from Resident #1's jeans pocket. In addition, the facility offered lockable storage for Resident #1 who declined the option and the facility reimbursed Resident #1 for the theft of money by RP2. The facility failure to protect Resident #1 from theft, is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +OR0001017400,385044,NF,10/19/2015,"Evidence and interviews indicated facility failure to ensure timely investigations for individual circumstances pertaining to Resident #1 and Resident #9 placing residents at risk for abuse and neglect of care. In addition, evidence and interviews indicated facility failure to provide adequate care and safety services for Resident #1, Resident #5, and Resident #9. The facility failure to provide Resident #1, Resident #5, and Resident #9 adequate care and safety services, placing residents at risk for injury and resulting in Resident #1_x001A_s behavior escalating and affecting other resident_x001A_s negatively, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,500,Substantiated,Substantiated,Neglect +OR0001029700,385044,NF,11/16/2015,Evidence and interviews indicated facility failure to ensure Hospice and facility staff followed Resident #2's care plan for a resident at risk for falls. Hospice staff failed to follow Resident #2's care plan and provide two-person transfer assistance resulting in Resident #2 sustaining a non-injury fall on or about 11/12/2015. This failure placed Resident #2 at risk for injury; relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001046000,385044,NF,12/31/2015,Evidence and interviews indicated facility failure to adequately assess and monitor Resident #3's neurological status after an unwitnessed fall on or about 12/30/2015 placing Resident #3 at risk for delayed treatment. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001049000,385044,NF,1/11/2016,"Evidence and interviews indicated facility failure to notify the physician that Resident #4 had not had a bowel movement from 12/2/2015 through 12/11/2015, a total of ten days placing Resident #4 at risk for discomfort. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001054100,385044,NF,1/22/2016,Evidence and interviews indicated facility failure to provide adequate care and services related to resident safety for Resident #5 and Resident #9 identified as elopement risks. Relevant portions of the complaint report investigation are attached.,3,1000,Not Substantiated,Substantiated, +OR0000667700,385045,NF,2/10/2011,Evidence and interviews indicated facility failed to provide adequate comfort measures when Resident #1's medical condition declined. Relevant portions of the survey report are attached.,2,0,Substantiated,Substantiated,Neglect +BC129510,385045,NF,2/27/2012,"Evidence and interviews indicated facility failed to protect Resident #1 from RP2's (CNA) rough handling on 02/27/2012. In addition, the facility investigated RP2 for rough handling residents on 08/25/2009, 04/19/2010 and 04/26/2010.",3,200,Not Substantiated,Substantiated, +OR0000782900,385045,NF,9/12/2012,Evidence and interviews indicated facility failure to implement adequate pressure ulcer interventions for Resident #1 resulting in Resident #1 sustaining a pressure ulcer. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000794704,385045,NF,11/16/2012,Evidence and interviews indicated facility failure to adequately administer Resident #1's medication on one occasion. Facility certified medication administration assistant left Resident #1's medications at the resident's bedside and Resident #1 took the medications.,1,0,Not Substantiated,Substantiated, +OR0000809400,385045,NF,2/4/2013,Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services regarding bowel care. Resident #1 sustained serious harm that required hospital treatment. These failures are considered neglect of care and constitute abuse.,3,2500,Substantiated,Substantiated,Neglect +BC132990,385045,NF,4/17/2013,Evidence and interviews indicated facility failure to ensure RP2 (CNA) provided Resident #1 timely call light response. Witness #1 indicated there were multiple response times of more than 20 minutes in response to Resident #1's call lights. RP2 was involved in six of those instances and was counseled about the issue.,2,0,Not Substantiated,Substantiated, +OR0000869900,385045,NF,1/3/2014,Evidence and interviews indicated the facility failed to ensure care-planned interventions were in place for Resident #1 who sustained an assisted non-injury fall in her/his room on 12/22/2013. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +BC148800,385045,NF,9/30/2014,Evidence and interviews indicated facility failure to assure Resident #1's rights resulting in Resident #1 sustaining a loss of dignity when waiting more than forty minutes for call light assistance.,2,,Not Substantiated,Substantiated, +OR0000889400,385045,NF,4/10/2014,"Evidence and interviews indicated facility failure to ensure witness #2 (licensed nurse) completed a thorough check for potential resident injuries before moving Resident #1 and failed to ensure that witness #3 (CNA) reviewed the Resident #1's care plan for safety interventions and failed to ensure witness #3 followed the care plan for bed mobility with incontinent care for Resident #1. Evidence and interviews indicated facility failure to ensure witness #3 utilized the required number of staff as care planned for Resident #1 for safety interventions. The facility failure to ensure the necessary care and services for Resident #1's safety resulting in Resident #1 sustaining broken bones is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000664501,385046,NF,1/27/2011,"Resident 5 was admitted October 2010 and re-admitted January 2011 with multiple diagnoses including a history of decubitus ulcers. Resident 5's MDS of November 2010 identified independent for transfers. Resident 5's care plan of 11/11/10 revealed a Stage II pressure ulcer on the left hip. Resident 5's 10/29/10 admission care plan did not indicate open skin areas, a history of skin issues or special needs. Resident 5's hospital transfer sheet of 1/11/11 indicated a skin wound to the top of the right buttock, but the facility admission form did not include any areas of skin breakdown. There was no report to Resident 5's physician until 1/23/11 relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000664502,385046,NF,1/27/2011,"Resident 10 was admitted January 2010 and Re-admitted December 2010 with multiple diagnoses including cognitive impairment, UTIs and a history of urosepsis. Resident 10's physician orders of December 2010 were for straight catheterization, but did not include specific parameters. Staff failed to obtain specific parameters resulting Resident 10 no voiding or being catheterized for over 8 hours on more than one occasion. Resident 10 was at risk for harm. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000664503,385046,NF,1/27/2011,Resident 10 did not receive IV antibiotics for three days when W1 failed to realize the first page of the orders had IV orders. The facility provided further training on following MD orders. The facility will conduct audits. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000664504,385046,NF,1/27/2011,"Resident 4 left the facility on 1/28/11 with an envelope of medication. Resident 4 returned and gave the envelope of medication to Staff 18 as reported by the resident and other staff. Staff 2 recalls speaking to Resident 4, but Resident 4 denies any administrative staff spoke with him/her regarding the missing medication. Staff 2 failed to fill out the incident report or adequately investigate the incident.",2,0,Not Substantiated,Substantiated, +OR0000664506,385046,NF,1/27/2011,Resident 4 would remove his/her wound dressing and expose his/her wound. Staff 12 reported finding maggots on the wound bed and on the top of the dressing. Staff 2 failed to fill out an incident report and adequately investigate or report the event.,3,0,Not Substantiated,Substantiated, +OR0000670300,385046,NF,2/18/2011,"Resident 1 sustained increased agitation, the facility staff called the police and Resident 1 was escorted to the ER. Resident 1 did not receive all physician ordered medication resulting in the change of condition. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +ES128828B,385046,NF,1/2/2012,RV reported waiting 4 hours for pain medication. RP2 does not recall RV very well; investigation interview occurred well over 1 1/2 months after the alleged event. No other staff were interviewed from the shift in question. Witnesses confirm lack of facility investigation and that RV did go an extended period of time between medication on 1/2/12. It was also reported that RV's oxygen tank ran out sometime prior to the next shift changing the tank. The facility failed to ensure a safe medication system resulting in some discomfort for RV over a four hour period of time. Evidence is inconclusive exactly when the oxygen tank ran out; just before it was noted or earlier. The facility failure is abuse by neglect of care and a Oregon Administrative Rule violation.,2,0,Substantiated,Substantiated,Neglect +ES118271,385046,NF,10/18/2011,"RV reported that RP2 , an outside contractor, punched RV. RV did not develop any marks or redness. RV has a history of targeting individuals and becoming combative, as well as, embellishing facts. RP2 told RV to go back in the facility. RP2 and W1 deny RP2 punched RV. Since, the contractor has some access to residents the facility must ensure the residents are safe. RV should have been treated with all due respect. The facility failure resulted in a Oregon Administrative rule violation.",1,0,Not Substantiated,Substantiated, +OR0000784900,385046,NF,9/20/2012,Staff 7 and Staff 4 give differing stories regarding Resident 1's transfer and subsequent swollen painful right knee. X-rays confirmed leg fractures. Staff 7 reported using a pivot transfer with Staff 4's help and Staff 4 reported using the Hoyer lift. Both staff deny Resident 1's legs were bumped or that Resident 1 was dropped. Reviewer notes the fracture may have occurred at any time during the transfer given the resident's history of osteoporosis. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.,3,0,Substantiated,Substantiated,Neglect +OR0000784901,385046,NF,9/20/2012,"Resident 1's in room care plan indicated dependency for all ADLs and monitor for non-verbal indicators of pain. Resident sustained a ""near miss fall"" at around 2:00 P.M. on 9/14/2012 and said ""owe"" at 4:00 P.M. during an attempted transfer. Staff reported the event to Staff 3 (RP2). Staff 3 failed to promptly assess and or report to resident's physician regarding resident's near miss fall and the swollen painful knee, but instead told the next shift (Staff 6). Staff 6 failed to notify the nurse practitioner in a timely manner; sent a fax at 8:00 P.M., but did not follow-up with a call when no response from the nurse practitioner. Resident received an x-ray the next day and was sent to the hospital at that time. Resident 1's evaluation and treatment was delayed for hours due to Staff 3 and Staff 6's lack of prompt assessment and or reporting of Resident 1's swollen painful knee. Relevant portions of the survey are attached. A federal civil penalty was proposed and an Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +OR0000812400,385046,NF,2/20/2013,"Resident 1 was admitted 1/11/2013 with multiple diagnoses and ordered medication including Dilaudid. A 1/15/13 physician order included Dilaudid 4 mg with Phenergan 50 mg IM one time per week for migraine. Another physician order dated 1/11/13 included Dilaudid 4mg 1/2 to 1 tablet orally every 4 to 6 hours for neck or limb pain. The resident fell on 1/24/13 and received Dilaudid 4 mg orally at 3:45 A.M. and at 7:30 A.M.; again at 4:00 P.M. and 7:30 P.M. ( less than 4 hours between doses). A nursing note at 4:00 P.M. on 1/25/13 indicated the resident was screaming in pain, the physician was notified with a triage nurse giving an order at 5:00 P.M. of 4 mg injection of Dilaudid per day through the weekend. On 1/25/13 at 9:30 to 10:00 P.M. resident awoke in pain and was given 4mg of Dilaudid orally and an IM dose of Dilaudid by Staff 3. Resident's level of consciousness decreased, EMTs were called and the resident was transferred to the hospital. Staff 3 failed to follow a reasonable standard of care in giving Resident 1 such a increased dose of Dilaudid. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +ES133296,385046,NF,5/18/2013,"RV4 has sworn at RV1 and other residents. RV4 moved a table and ""tapped"" RV2's foot as RV2 was in RV4's ""spot"", RV2 did not sustain notable injury. RV1's care plan of 5/15/13 noted monitoring of interactions with RV4. RV4's care plan was updated for monitoring, but not until 5/14/13. Staff failed to monitor RV3 allowing RV3 to go up a hill in RV's assistance device, become ""stuck"" and require multiple staff to assist RV back down the hill. The facility failed to thoroughly assess and intervene in RV3's behaviors placing RV in harms way. Oregon Administrative Rule violation occurred.",2,,Inconclusive,Substantiated, +OR0000939500,385046,NF,12/16/2014,"Resident 2 was admitted 2014 with multiple diagnoses including urinary retention. On 11/08/2014 Resident 2 was found with a blood saturated brief at approximately 6:00 A.M. Resident 2 had pulled out his/her Foley catheter around 4:00 A.M., Staff 2 (LPN) was notified at that time by the night C.N.A., Staff 2 failed to notify the resident's physician and failed to fully assess the resident at first notification, failed to go back and look in the resident's brief and failed to properly document the events. Resident's physician was not notified in a timely manner; physician was notified two hours after the event. The resident lost a significant amount of blood; and was at risk for further harm due to delay in physician notification and a delay in physician treatment orders. Failure to provide adequate care and services resulting in negative outcome constitutes abuse. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES149275,385046,NF,11/16/2014,"RV was prescribed a pain medication with a dosage of 20 mg every 8 hours. The pharmacy sent a different dosage strength of medication , but RV's MAR was not changed to reflect the new strength of medication. RP2 gave four (20mg) tablets rather than four (5mg) tablets as noted on the MAR. RP2 found his/her error and immediately notified RV and RV's physician. Staff monitored RV's vital signs which remained stable. RV reported he/she was kind of scarred, equilibrium was off a little and that night slept real good. The facility failed to have an adequate medication system in place resulting in RV receiving the wrong dose of medication and sustaining a small change in condition, but potential for great harm existed. The facility neglect of care constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES152555,385046,NF,8/17/2015,RP2 failed to follow RV's care plan regarding RV's behaviors. RP2 failed to promptly exit RV's behaviors escalated as RV told RP2 to leave RV's room. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +ES154036,385046,NF,12/23/2015,RP2 failed to insure RV was accompanied to the health department. RV was at risk for harm. The facility provided further in-service to RP2 regarding RV's needs. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ES164902,385046,NF,3/7/2016,"RV2 was unable to provide relevant information. RV1 reported remembering the event, reported RV2 scratched them and RV1's injury is healed as reported 3/30/2016. RV1 reported staying away from RV2. W2 denied observing the incident between RV1 and RV2 and has not witnessed other events, but has heard of events regarding RV2. W4 reported RV2 does not like others in RV2's space, RV1 got close and RV2 ""smacked"" RV1's hand in the drawer; RV1 sustained a bruise. W3 heard ""get the hell out of my way"" and found RV1 shaking his/her hand. RV1 and RV2 were in an incident on 3/4/2016 when RV2 grabbed RV1. W4 reported a prior event a couple of months ago. Documentation review indicates no care plan changes for either RV1 or RV2 for the 3/4 and 3/6/2016 events. The facility failure t protect RV1 from RV2 resulting injury constitutes neglect and abuse. Oregon Administrative rule violations occurred.",2,200,Substantiated,Substantiated,Neglect +DL116070,385049,NF,1/5/2011,"RV2 reported RP2 was rough when turning RV1. RV1, who has fragile skin, showed no signs of trauma. RV2 reported RP2 got mad and started mumbling when RV2 told RP2 ""jokingly"" to slow down. RV1 was unable to give relevant information. RP2 denies mistreating RV1, admitted being ""angry"" when RV2 called him/her a ""klutz"", admitted should have left the room and did throw a pillow into RV1's chair while mumbling. RP2 admitted his/her behavior could have been perceived as intimidating. RP2 did leave RV3's room after RV3 was screaming at RP2. W2 and W3 finished RV3's care. The facility suspended RP2 and then terminated his/her employment. RP2 failed to treat RV1 and RV2 with all due respect.",2,0,Not Substantiated,Substantiated, +DL117714,385049,NF,8/3/2011,"Facility staff placed narcotic medication RV had brought from home in a locked cupboard, but not in the locked narcotic drawer as facility policy indicates. RV did not have an order for this medication while in the facility. Multiple staff knew RV's narcotic medication was in the locked cupboard, but staff did move the medication to the locked narcotic drawer as facility policy would suggest. RV's medication came up missing, but there is insufficient evidence as to who may have taken the medication. The facility offered reimbursement to RV's spouse, but the offer was declined. All staff received further in-service.",2,0,Substantiated,Substantiated,Financial abuse +OR0000768900,385049,NF,6/22/2012,"Resident 1 was admitted to the facility 6/13/2012 with multiple diagnoses. The resident's 6/15/2012 repealed risk for falls, watch for hypotension and syncope and further safety intervention including a fall matt, one person assist with transfers and use of a walker. On 6/18/2012 staff heard a noise, found the resident laying on the floor and no alarm sounding. Staff 3 last assisted the resident at 1:30 A.M., observed the resident sleeping about 2:30 A.M. and believed the alarm was turned on. There is a less than probable chance the resident turned off the alarm. The resident stained a soft tissue injury. Alarms in and of themselves will prevent all falls, the facility took action to prevent a future similar event. Note: Staff 4 reported Staff 3 may have lost track of turning the alarm on due to multiple items he/she assisted the resident. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +DL129974,385049,NF,5/1/2012,"W2 and W3 found discrepancies in narcotic and MAR records for RV1 through RV10 from March 2012 to May 2012. No evidence exists indicating any RVs were in pain. Preponderance of evidence supports misappropriation of RV1 through RV10's narcotic medication by RP2. Evidence supports RP2 signing off RV1 through RV10 narcotics when RP2 was not in the facility working. RP2 had been responsible for transferring the narcotic book for the last 9 months and some of the narcotic books were missing at the time of the investigation. W2 and W3 looked for the books, but were unable to find them. The facility failed to ensure a safe medication system resulting continued theft of RV1 through RV10's narcotic medication, as well as, failure to ensure accurate medication records. This facility failure constitutes abuse and an Oregon Administrative Rule violation.",3,400,Substantiated,Substantiated,Financial abuse +DL121942,385049,NF,12/11/2012,"Witness 2 reported RV1's prior behavior was not shared by RV1's previous living facility. W2 reported hearing RV1 make comments to opposite gender resident and reported RV1 had touched staff inappropriately. W4 reported visiting RV2 daily and on one of the first visits RV1 told W4 that RV1 was not supposed to be around opposite gender. RV2 reported staff (unknown) were in the area at the time RV1 would not let go of RV2. RV2 sustained bruises to his/her head/arm area. RV1's room care plan noted not to allow RV1 to sit with opposite gender, redirect and remove from the area or from conflict which was not followed at the time of the event. The facility failure represents neglect of care and a Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +DL133449B,385049,NF,6/6/2013,"RV reported missing items and believed a wandering resident may have taken the items. W3 reported the facility did not replace the items, but negotiated with RV regarding a debt owed. The facility failed to adequately protect RV from theft; be it a resident or another person. An Oregon Administrative Rule violation occurred.",0,,Substantiated,Substantiated, +DL133604,385049,NF,6/24/2013,The facility failed to adequately monitor RV2 when RV2 was near RV1. RV2 was physically aggressive toward RV1; pulled RV1's hair. Neither RV sustained visible sign of injury. Failure to monitor RV2's behaviors resulted in minor harm to RV1 and constitutes abuse/neglect. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Neglect +OR0000847100,385049,NF,8/20/2013,"Resident was admitted 2010 with multiple diagnoses. The resident sustained a fall on 8/15/13 with a 8/19/13 care plan update. The resident fell 8/19/13 without noted injury. The facility investigation found the resident call light had been activated a long time, resident attempted self transfer and fell. Various staff observed the call light, but were assisting other residents. The facility failed to provide the resident with adequate supveions and assistance with transfer to prevent resident self transfer and fall. Relevant survey pages are attached. Enforcement action was requested. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000847101,385049,NF,8/20/2013,Staff failed to answer resident call light within a timely period resulting in resident self transfer with a fall. Staff reported there could be times when the resident would have to wait for assistance. The call light response report indicated up to 77 times in which the call light response was exceeding 15 minutes. Extended time periods awaiting staff assistance to transfer to the toilet or resident self transfer ending in a fall indicates neglect of care and constitutes abuse. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Neglect +DL135155,385049,NF,11/19/2013,"RP2 patted or ""tapped"" RV's penis in a ""joking manner"" after providing care while stating something regarding ""luck"". RP2 and witnesses deny the touch was sexual. RV is unable to give relevant information, but a reasonable person would find RP2's actions / comments inappropriate and humiliating. RP2 emotionally abused RV through humiliation. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +DL146060,385049,NF,2/5/2014,"W1 observed RP2 pat RV's penis on two occasions, but failed to promptly report the occurrences. W1 reported the incidents occurred prior to the one witnessed by a nursing student (student came into the facility in October 2013). W2 reported a similar event with RP2 that occurred after W5 left and before students arrived. The facility terminated RP2 after hearing what W1 and W2 observed. W5 was unavailable for interview. RP2 denies any such events other than the one with the nursing student and a brief encounter with W5. RP2's patting RV's genital area, even if not sexual in intent, is a humiliating event and constitutes mental/emotional abuse. An Oregon Administrative Rule violation occurred.",3,,Inconclusive,Substantiated,Verbal/Mental abuse +OR0000863601,385049,NF,11/18/2013,"Resident 1 was admitted 11/1/2013 with multiple diagnoses. The resident was not bathed from 11/1/2013 until 11/12/2013. the resident's care plan failed to indicate a schedule or time preference for showering. The resident was unable to be interviewed. Staff 3reported the resident was on one floor's bathing schedule, but not on the other floor's schedule. The resident did not received preferred bathing. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rules were violated.",2,,Not Substantiated,Substantiated, +OR0000864002,385049,NF,11/19/2013,Resident 2 was admitted 11/7/2013 with multiple diagnoses including post hospitalization for a fractured femur and dementia. The resident's physician orders were for acetaminophen 650 mg every 6 hours as needed for pain without any other pain medication ordered. Staff failed to premedicate resident on 1/14/2013 prior to removing approximately 17 to 18 staples. The resident did express signs of temporary discomfort. Staff failed to check to see if the resident had been premedicated; staff only thought the resident had been medicated. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred..,2,,Not Substantiated,Substantiated, +OR0000864003,385049,NF,11/19/2013,"Resident's fall risk assessment identified risk for falls. The resident sustained a fall with a small bruise on 11/7/2013, the resident reported attempting to get up. The resident's care plan called for use of a motion alarm. The alarm was not implemented; the alarm was turned off. Staff 13 reported possibly forgetting to turn the alarm back on. Alarms in and of themselves do not prevent all falls, but the resident care plan was not followed. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rules were violated.",2,,Not Substantiated,Substantiated, +DL147681A,385049,NF,7/6/2014,"RV reported telling the nurse the day before RV did not want or need a suppository. RV reported RP2 was ""determined"" to get RV into the bathroom and put the suppository up there. RV was inconsistent as to when RV had BMs. RP2 admitted not saying anything to RV before administering the suppository. Due to poor facility communication neither W1 or RP2 knew RV had refused a suppository the day before. RP2 was given written warning and staff were educated on resident rights. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +DL147681B,385049,NF,7/6/2014,"RP2 gave a medicated suppository before taking the CMA test and being certified as a CMA. RP2 had been trained by and supervised by a nurse, but believed W1 had directed RP2 to give the suppository. W1 was only inquiring whether or not RP2 was able to give the suppository. While RV had some pain at time of the suppository insertion and blood in RV's tool, evidence is not sufficient the insertion of the suppository or RV's hard stool caused the bleeding. RP2 has since been issued a CMA license on 8/11/2014. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +DL150045,385049,NF,1/14/2015,"RP2 admitted to the investigator and W3 taking resident's narcotic medication (specifically RV1, RV2 and RV3) for RP2's own personal use; and substituting other medication for RV1's narcotic medication. The medication RP2 was substituting was given in excess of the safe level to be given for that medication. RV1 is alert, oriented and capable of knowing when his/her narcotic medication looked different. RV1 reported noticing the medication he/she was receiving (supposedly RV1's narcotic medication) was not helping RV's pain. Additionally RP2 stated asking other staff to sign for destroyed medication without the staff observing the medication being destroyed and RP2 stated 4-5 and named 6. W4, 5 and 6 deny ever observing RP2 destroy medication. Narcotic counts were off and RP2's documentation was inaccurate placing residents at risk for harm. RP2's actions and inactions constitute abuse. The facility failed to ensure an adequate medication system for counting, documenting, reviewing and or destroying narcotic medication. This failure resulted in repeat theft of resident narcotics; and continued resident (RV1) pain and discomfort. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",3,500,Substantiated,Substantiated,Financial abuse +OR0000995300,385049,NF,8/19/2015,"Resident 92 was admitted 7/2015 with a fractured tibia, degenerative arthritis and decreased mobility. The resident utilized a right knee immobilizer. The admission orders included decubitus precautions and therapy orders. The resident admission assessment did not include skin impairment or skin issues. The facility failed to gain orders to remove the brace and provide brace management until after the resident developed a decubitus ulcer. The facility failed to promptly transcribe physician orders and update the resident's care plan . Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000661800,385053,NF,1/14/2011,"The facility failed to consistently follow physician orders for Resident #1. In addition, the facility failed to implement adequate interventions to reduce risk of accident. Progress notes dated January 14, 20011 indicated Resident #1 was found on the floor, was sent to the hospital for evaluation where it was determined Resident #1 sustained a spinal compression fracture. Relevant portions of the survey report are attached.",2,,Substantiated,Substantiated,Neglect +ES116519A,385053,NF,3/10/2011,Facility failed to assure Resident #1 was provided adequate care assistance resulting in Resident #1 sustaining a continued per-area rash.,2,600,Substantiated,Substantiated,Neglect +ES116519B,385053,NF,3/10/2011,Facility failed to ensure sufficient staffing to meet residents' care needs.,2,0,Substantiated,Substantiated,Neglect +OR0000700400,385053,NF,7/19/2011,Evidence and interviews indicated facility staff failed to ensure care planned interventions were in place. Resident #1 sustained two falls on 7/16/2011 requiring hospital treatment. Relevant portions of the survey report are attached.,2,300,Substantiated,Substantiated,Neglect +ES117107,385053,NF,5/27/2011,Facility failed to ensure Resident #1 received physician ordered PT services during the five days Resident #1 resided at the Facility.,2,0,Not Substantiated,Substantiated, +ES118464,385053,NF,11/9/2011,"Evidence and interviews indicated facility failure to ensure Resident #1 received timely oxygen per physician orders on November 9, 2011 resulting in Resident #1 sustaining shortness of breath and significant discomfort.",3,450,Substantiated,Substantiated, +ES120124A,385053,NF,4/25/2012,Evidence and interviews indicated Resident #1 was given half of her/his ordered pain medication on 02/11/2012 and 02/12/2012. There were no documented adverse effects to Resident #1 as a result of these medication errors.,2,0,Not Substantiated,Substantiated, +ES120124B,385053,NF,4/25/2012,"Evidence and interviews Resident #1 was administered double doses of her/his ordered medications on 04/25/2012. Resident #1's afternoon medications were given in full the afternoon of 04/25/2012, despite physician orders to hold doses of two medications. There were no documented adverse effects to Resident #1 as a result of these medication errors.",2,0,Not Substantiated,Substantiated, +ES129083,385053,NF,1/26/2011,Evidence and interviews indicated facility failure to maintain an adequate medication system resulting in residents receiving medications incorrectly. One of these medication errors resulted in Resident #2 sustaining increased confusion.,3,400,Substantiated,Substantiated,Neglect +ES121742,385053,NF,11/26/2012,"Evidence and interviews indicated facility failure to adequately care plan, intervene and document regarding Resident #1's behaviors toward Resident #2 on 11/26/2012.",2,0,Not Substantiated,Substantiated, +OR0000789900,385053,NF,10/18/2012,Evidence and interviews indicated the facility failed to monitor Resident #1's self-releasing seat belt on 10/15/2012 resulting in Resident #1 sustaining injury and requiring hospital treatment. Relevant portions of the complaint report investigation are attached.,2,250,Substantiated,Substantiated,Neglect +ES132068,385053,NF,12/30/2012,Evidence and interviews indicated facility failed to ensure 01/01/2013 physician orders for a Dysphasia Mechanical Soft diet for Resident #1 were followed. On 01/09/2013 Resident #1 received a whole waffle with whipped topping for breakfast. Evidence and interviews indicated facility failed to ensure Resident #1 received showering assistance over a seven-day time period.,2,0,Not Substantiated,Substantiated, +ES132377,385053,NF,11/12/2012,Evidence and interviews indicated facility failure to adequately administer Resident #1's seizure medication. A physician order indicated Resident #1's seizure medication dosage be discontinued. The facility failed to discontinue administering the seizure medication dosage. The error was discovered on 01/08/2013.,3,250,Not Substantiated,Substantiated, +ES121981,385053,NF,12/25/2012,Resident #4 said she/he requested PRN pain medication between midnight and 2:00 am on 12/25/2012. Resident #4 said she/he was in continued pain until she/he was given pain medication by morning shift staff. The Facility_x001A_s failure to provide Resident #4 timely pain medication resulting in Resident #4 sustaining continued pain and discomfort are considered neglect of care and constitute abuse.,2,300,Substantiated,Substantiated,Neglect +ES132531,385053,NF,2/26/2013,Evidence and interviews indicated facility failure to properly plan Resident #1_x001A_s care resulting in Resident #1 sustaining skin injury is considered neglect of care and constitutes abuse.,3,400,Substantiated,Substantiated,Neglect +OR0000820900,385053,NF,3/29/2013,"Evidence and interviews indicated facility failure to accurately assess, care plan, monitor, and provide consistent interventions and act timely on dietary recommendations for Resident #1. The facility failure resulted in Resident #1 not receiving appropriate services to promote healing and prevent a new pressure sore from developing. Relevant portions of the complaint report investigation are attached; federal penalty recommended.",3,0,Substantiated,Substantiated,Neglect +ES133956,385053,NF,7/29/2013,Evidence and interviews indicated facility failure to assure staff provided adequate peri-care assistance to Resident #1 and Resident #2 resulting in residents waiting in wet (urine) undergarments for approximately an hour. This failure is considered neglect of care and constitutes abuse.,2,,Substantiated,Substantiated,Neglect +ES134187,385053,NF,8/19/2013,"Evidence and interviews indicated facility failure to ensure that RP2 did not provide Resident #1 with a haircut when Resident #1 indicated she/he did not want a haircut. The facility failure to assure Resident #1's right to decline care is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +ES133973A,385053,NF,7/31/2013,"Evidence and interviews indicated facility failure to provide Resident #1 timely call light assistance. In addition, Resident #1 indicated she/he would use a tab alarm to request staff assistance and her/his tab alarm was taken away. Resident #1 said facility staff told Resident #1, ""every time we heard your tab alarm go off, we said it's just [Resident #1].""",2,,Not Substantiated,Substantiated, +OR0000846001,385053,NF,8/15/2013,"Evidence and interviews indicated facility failure to ensure Resident #5 had fluids within her/his reach in her/his room. Resident #5_x001A_s care plan dated 08/21/2013 indicated staff should encourage fluid intake each time staff, _x001A__x001A_walked into room; ICE water thin liquids_x001A__x001A_ August and September 2013 meal monitoring for Resident #5 showed fluid intake ranged from 240 ccs per day to 1260 ccs per day. The Facility failure to provide Resident #5 the necessary care and services to promote fluid intake and dietary needs placed Resident #5 at risk of serious harm. Relevant portions of the complaint report investigation are attached.",3,,Not Substantiated,Substantiated, +OR0000846003,385053,NF,8/15/2013,Based on interviews and evidence it was determined the facility failed to ensure Resident #5 received the necessary care and services related to her/his dietary needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000857903,385053,NF,10/14/2013,Evidence and interviews indicated facility failure to follow physician_x001A_s orders regarding laboratory testing for Resident #1_x001A_s PT/INR levels and the administration of Coumadin (anti-coagulation) medication and Tizanidine (muscle relaxer). The Facility_x001A_s failure to follow physician_x001A_s orders for Resident #1_x001A_s laboratory testing and medication administration placed Resident #1 at risk of unmet needs. Relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000857902,385053,NF,10/14/2013,"Evidence and interviews indicated facility failure to obtain a physician_x001A_s orders for a Foley catheter for Resident #1. In addition, evidence and interviews indicated facility failure to maintain documentation regarding Resident #1's catheter care. Staff #7 stated that Resident #1 complained the Foley catheter was uncomfortable and Resident #1 routinely asked for the catheter to be removed. + + + +The Facility failure to prevent Resident #1_x001A_s unreasonable discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +ES134342,385053,NF,8/31/2013,Evidence and interviews indicated the facility failed to adequately investigate swelling and discoloration observed by Witness #2 under Resident #1's left eye on 08/30/2013. The facility failure to adequately investigate Resident #1's change of condition to rule out abuse is a violation of the Oregon Administrative Rules governing nursing facilities.,2,,Not Substantiated,Substantiated, +OR0000877102,385053,NF,2/12/2014,"Evidence and interviews indicated facility failure to ensure Staff #5 (LPN) verified Resident #2's hospital transfer orders for the use of oxygen, and Staff #8 (LPN), Staff #9 (LPN) and Staff #4 (RN) administered oxygen to Resident #2 without obtaining a physician's order. The facility failure placed Resident #2 at risk for receiving unnecessary treatment and services and is considered a violation of Oregon Administrative Rules. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000877104,385053,NF,2/12/2014,Evidence and interviews indicated facility failure to obtain physician's orders for the administration of Resident #2's oxygen. This failure placed Resident #2 at risk for receiving unnecessary treatment and services and is considered a violation of Oregon Administrative Rules. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000877103,385053,NF,2/12/2014,Evidence and interviews indicated facility failure to develop a plan of care including potential risks and facility interventions regarding the use of Coumadin (anticoagulant medication) for Resident #2. This failure placed Resident #2 at risk for complications related to the use of anticoagulant medications and is considered a violation of Oregon Administrative Rules. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000895100,385053,NF,5/7/2014,"Evidence and interviews indicated facility failure to honor Resident #2_x001A_s right to leave the facility for an outing and ensure the resident was free from reprisal for exercising that right. As a result, Resident #1 was improperly discharged from the facility. In addition, evidence and interviews did not indicate Resident #1 was provided adequate notice requirements regarding her/his denial to return or readmit to the facility. Evidence and interviews indicated facility failure to appropriately discharge Resident #2 from the facility. As a result, Resident #2 was at risk of complications from being improperly discharged from the facility. Relevant portions of the complaint report investigation are attached.",4,2000,Not Substantiated,Substantiated, +ES147775,385053,NF,7/14/2014,"Evidence and interviews indicated RP2 (CNA) provided inadequate care assistance for Resident #1 on or about 07/14/2014. Evidence and interviews indicated RP2 failed to treat Resident #1 with consideration, respect and dignity while providing care.",2,,Not Substantiated,Substantiated, +ES147561A,385053,NF,6/24/2014,"Evidence and interviews indicated facility failure to ensure staff followed Resident #1_x001A_s care plan. On 6/24/2014 RP2 (CNA), RP3 (CNA) and RP4 (CNA) disregarded Resident #1_x001A_s right to refuse care assistance. Facility staff provided inconsistent reports regarding what methods of restraint were used when they provided Resident #1_x001A_s care on 6/24/2014. However RP2, RP3 and RP4 each, indicated some form of restraint was used on Resident #1 when she/he became combative with unwanted care assistance.The facility failure to follow Resident #1_x001A_s care plan, resulting in staff restraining Resident #1 while providing care assistance Resident #1 refused are violations of resident rights, are considered neglect of care and constitute abuse.",3,400,Substantiated,Substantiated,Neglect +ES147686,385053,NF,7/5/2014,"Evidence and interviews indicated facility failure to ensure Resident #1's therapeutic dietary needs were met. On June 22, 2014 Resident #1 was served dinner that included tomato. Resident #1 has a known allergy to tomatoes as indicated on her/his food services card. The Facility failure to ensure Resident #1's therapeutic diet needs resulting in Resident #1 sustaining an allergic reaction after eating tomatoes she/he was erroneously served with dinner, are considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +ES149260,385053,NF,11/15/2014,Evidence and interviews indicated RP2 (licensed nurse) used a blood pressure monitor to check Resident #1's blood pressure on 11/16/2014 and when doing so caused a two-inch skin tear on Resident #'1 right forearm. Resident #1 has fragile skin and was on an anticoagulant at the time of the incident.,2,,Not Substantiated,Substantiated, +ES148659,385053,NF,9/22/2014,"Evidence and interviews indicated facility failure to provide Resident #1 adequate pain medication administration. Resident #1 was admitted to the facility from the hospital post surgery on 9/22/2014 at approximately 11:00 am and she/he was scheduled to receive an ordered pain medication every four hours. Facility progress notes indicated Resident #1 was in constant pain after admitting to the facility on 9/22/2014. Resident #1 was administered her/his first ordered pain medication on 9/23/2014 at approximately 7:39 am. The Facility failure to ensure Resident #1 received pain medication as ordered resulting in Resident #1's continued pain and discomfort are violations of resident rights, are considered neglect of care and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000916001,385053,NF,8/13/2014,Evidence and interviews indicated facility failure to provide adequate care and services related to administering Resident #1's narcotic pain medication as ordered by a physician with a potential of an increased dose for an extended duration. This failure placed Resident #1 at risk of receiving unnecessary medication. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000916002,385053,NF,8/13/2014,"Evidence and interviews indicated facility failure to ensure facility staff accurately documented residents' clinical records related to medication and catheter care for Resident #1, Resident #6 and Resident #8. This failure placed residents at risk for inaccurate clinical records. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000931901,385053,NF,11/5/2014,Evidence and interviews indicated facility failure to notify Resident #1's responsible party of a deterioration in a pressure ulcer. This failure placed Resident #1's responsible parties at risk of not being informed.,2,,Not Substantiated,Substantiated, +OR0000931902,385053,NF,11/5/2014,Evidence and interviews indicated facility failure to provide adequate medically related social services for Resident #1 who required staff assistance to attend a physician appointment. Facility failure to ensure adequate care and services related to Resident #1's medical appointment placed Resident #1 at increased risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000946500,385053,NF,1/28/2015,"Evidence and interviews indicated facility failure to administer Resident #2's medication according to physician orders related to the treatment of a right heel wound, placing Resident #2 at increased risk for worsening pressure sores. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000946501,385053,NF,1/28/2015,"Evidence and interviews indicated facility failure to provide Resident #2 adequate care and services related to wound care and pressure sore precautions for a right heel pressure sore, placing Resident #2 at increased risk for worsening pressure sores. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +ES151487,385053,NF,5/9/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from the theft of $45.00 from her/his room. Evidence and interviews indicated facility failure to provide Resident #1 with locking storage for her/his money. In addition, facility staff became aware of Resident #1's allegation regarding the theft of her/his money on 5/14/2015 however facility staff failed to adequately report the theft of Resident #1's money to law enforcement and the Department. The facility failure to protect Resident #1 from financial exploitation, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000972600,385053,NF,5/26/2015,Evidence and interviews indicated facility failure to notify Resident #2's responsible party regarding a fall. The facility failure to notify Resident #2's responsible party regarding Resident #2's fall with injury placed Resident #2's responsible party at increased risk for lack of involvement in decision-making. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000972601,385053,NF,5/26/2015,"Evidence and interviews indicated the facility failed to ensure adequate care and services were implemented for Resident #2's safety. Resident #2's care plan indicated the resident was at risk for falls due to balance problems, medications, and cognition. Progress notes for 5/12/2015 indicated Resident #2 was found on the floor with an abrasion. On 5/13/2015 staff #2 (licensed nurse) requested the day nurse obtain orders for a tab alarm for Resident #2. However, facility staff failed to ensure staff placed a tab alarm on Resident #2. On 5/14/2015, Resident #2 was found on the floor at 1:22 am; Resident #2 was observed to seize. The facility failure to provide adequate care and safety services, resulting in Resident #2 sustaining an unwitnessed fall with blunt force head trauma causing her/his death is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +ES152162,385053,NF,7/20/2015,Documentation indicated Resident #1's bandage was changed on 7/2/2015 at the wound clinic. Evidence and interviews indicated facility failure to ensure Resident #1's wound care was provided three times weekly as ordered on 7/3/2015. On 7/6/2015 facility staff changed Resident #1_x001A_s bandage and observed maggots were on the wound.,2,,Not Substantiated,Substantiated, +ES152787,385053,NF,9/4/2015,"Evidence and interviews indicated the facility failure to protect Resident #1 and Resident #2 from mental abuse and from inappropriately moving Resident #1 to another area of the facility. On or about 9/1/2015 Resident #1 was moved to the opposite end of the facility. Prior to moving Resident #1, Resident #1 and Resident #2 shared a room. Resident #1 and Resident #2 were distraught over the room change, however they were not allowed to move back together in spite of requests to see each other and requests to share a room again. Resident #2 refused to eat until she/he could see Resident #1 again, ultimately sustaining decreased blood pressure and becoming unresponsive. The facility failure to protect Resident #1 and Resident #2 from mental abuse and an inappropriate move within the facility resulting in both residents becoming distraught is a violation of resident rights, considered mental abuse, and constitutes abuse.",3,800,Substantiated,Substantiated,Verbal/Mental abuse +OR0001015402,385053,NF,10/14/2015,"Evidence and interviews failed to indicate facility failure to provide Resident #164 adequate care and safety services related to an unwitnessed fall on or about 8/25/2015. In addition, an expanded complaint report investigation identified evidence and interviews that the facility failed to investigate an incident of self-harm for Resident #34 and facility failed to provide care and adequate supervision for Resident #34. Evidence and interviews also indicated facility failure to assess Resident #32 and Resident #114 were safe to smoke and failed to develop a plan of care based on the smoking assessments. The facility failed to implement a smoking care plan for Resident #32 and Resident #114 placing residents at risk for smoking related injuries. Evidence and interviews indicated the facility failed to provide adequate fall interventions for Resident #17 and Resident #139; relevant portions of the complaint report investigation are attached.",3,600,Not Substantiated,Substantiated, +OR0001017000,385053,NF,10/19/2015,Evidence and interviews indicated facility failed to clarify with the physician and or the pharmacy to ensure Resident #139 did not have a cross-sensitivity (a reaction to a medication that predisposes a person to react similarly to a different but related medication) to an opioid-like pain medication. This placed Resident #139 at increased risk for adverse drug reactions; relevant portions of the complaint report investigation are attached.,3,450,Not Substantiated,Substantiated, +OR0001017001,385053,NF,10/19/2015,"Evidence and interviews indicated facility failed to ensure Resident #139's pressure alarm was functioning and facility failed to adequately investigate an unwitnessed fall placing Resident #139 at risk for injury on 10/11/2015 when Resident #139 sustained a fall in her/his room. In addition, an expanded sample indicated facility failed to ensure facility staff properly latched Resident #17's wheelchair to the floor on the bus on 12/22/2015 when on an activities outing. This failure resulting in Resident #17 sustaining a fall and subsequent skin tear, relevant portions of the complaint report investigation are attached.",3,,Not Substantiated,Substantiated, +OR0001041804,385053,NF,12/18/2015,"Evidence and interviews indicated facility failure to obtain Resident #4's CBG (capillary blood glucose) level prior to meals. The failure to obtain Resident #4's CBG reading prior to meals placed Resident #4 at risk for inconsistent CBG readings. In addition, evidence and interviews indicated facility failure to ensure Resident #164's records adequately reflected nasogastric care services and failed to ensure wound care documentation was complete and readily available for Resident #17; this failure placed residents at risk for inaccurate documentation of care services; relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001041805,385053,NF,12/18/2015,Evidence and interviews indicated facility failure to ensure an appropriate barrier was worn by staff #10 (laundry staff) when handling soiled linen to prevent the potential spread of infection to clean linen. This failure placed residents at risk for cross contamination; relevant portions of the complaint report are attached.,2,,Not Substantiated,Substantiated, +OR0001048400,385053,NF,1/7/2016,"Evidence and interviews failed to indicate facility failure to adequately administer Resident #51's Depakote. Evidence and interviews with an expanded review of additional residents indicated facility failure to monitor adverse side effects and the effectiveness of antipsychotic medications for Resident #34. This failure placed Resident #34 at risk for inappropriate psychotropic drug use. In addition, evidence and interviews indicated facility failure to clarify with the physician and or the pharmacy to ensure Resident #139 did not have a cross-sensitivity (a reaction to a medication that predisposes a person to react similarly to a different but related medication) to an opioid-like pain medication. This placed Resident #139 at increased risk for adverse drug reactions. Relevant portions of the complaint report investigation are attached.",3,400,Not Substantiated,Substantiated, +BC116121,385055,NF,1/6/2011,"A sign is posted telling staff to remind RV1 beginning of the shift not to touch other residents. RV was placed on 15 minute checks. RV had refused to sign a contract regarding his/her behaviors. There was a prior event of 10/13/10 and a second event on 11/8/10 before this event of 1/6/11. Record review found psychotropic medication changes on 11/12/10 and 12/22/10. W1 reported as of the 12/14/10 care conference interventions of reminding RV1, etc. were not tried, but not sure of this given the care plan of 11/10/10. The facility failed to provide a safe environment for residents within the facility given RV1's continued behaviors.",2,0,Not Substantiated,Substantiated, +BC117707,385055,NF,7/27/2011,RV is missing a ring. RV is cognitively impaired and may have removed the ring him/herself. Staff observed the ring on RV's finger the morning of 7/27/11 and it was noted as missing at 3:00 P.M. on 7/27/11. The facility is attempting to establish the ring's value and provide reimbursement.,2,0,Not Substantiated,Substantiated, +BC128841,385055,NF,12/13/2011,"On 12/12/11 RP2 failed to apply RV's ""crock"" foot wear prior to showering RV as RV's care plan directs. While RV sustained an abrasion to his/her toe that found on 12/13/11, evidence is not conclusive the abrasion occurred during the shower. RV is unable to give relevant information. RP2 failed to ensure she/he followed all of RV's care plan.",2,0,Not Substantiated,Substantiated, +BC128835,385055,NF,12/31/2011,Evidence and interviews indicated RP2 (licensed nurse) gave Resident #1 an incorrect medication taken from the emergency box supplies when Resident #1 had a medical emergency on 12/31/2011. RP2 failed to timely notify Resident #1's physician regarding the medication error. RP2 failed to document the error and did not update Resident #1's medication administration record to reflect the correct medication was administered. Unable to assess a sanction based on this allegation due to facility change of ownership on 1/1/2012.,3,0,Not Substantiated,Substantiated,Neglect +OR0000735500,385055,NF,12/21/2011,Evidence and interviews indicated facility failed staff failed to follow Resident #1's care plan and ensure fall prevention interventions were in place. On 12/18/2011 Resident #1 sustained a non-injury fall.,2,0,Not Substantiated,Substantiated, +OR0000736800,385055,NF,12/28/2011,Evidence and interviews indicated facility staff failed to ensure fall interventions were in place for Resident #2 on 12/26/2011. Resident #2 attempted to self-transfer out of bed and sustained a non-injury fall.,2,0,Not Substantiated,Substantiated, +BC132820,385055,NF,3/31/2013,Evidence and interviews indicated facility failure to provide Resident #1 a safe environment resulting in Resident #1 sustaining a burn to her/his torso area. The facility failure is considered neglect of care and constitutes abuse.,3,400,Substantiated,Substantiated,Neglect +OR0000918400,385055,NF,8/28/2014,"Evidence and interviews indicated facility failure to implement care planned interventions for Resident #1. Facility failure to provide Resident #1 care and services as planned to keep residents safe from injury resulting in Resident #1 sustaining a fractured ankle is a violation of resident rights, considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached, federal penalty recommended.",3,,Substantiated,Substantiated,Neglect +OR0000917000,385055,NF,8/22/2014,"Evidence and interviews indicated facility failure to provide care and services as care planned to keep Resident #2 safe from injury. Facility failure to provide Resident #2 care and services as planned to keep residents safe from injury is a violation of resident rights, considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached, federal penalty recommended.",3,,Substantiated,Substantiated,Neglect +GP117253,385064,NF,6/10/2011,"RP2 financially exploited Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10. Evidence and interviews indicated RP2 took $11,938.22 from resident PIF accounts.",4,2500,Substantiated,Substantiated,Financial abuse +GP118203,385064,NF,10/12/2011,"Evidence and interviews indicated the facility failed to ensure a safe medication system. Resident #1, Resident #2 and Resident #3's narcotic pain medications were diluted with an unknown substance resulting in residents receiving incorrect doses of narcotic pain medication.",3,1200,Substantiated,Substantiated,Financial abuse +OR0000766300,385064,NF,3/16/2012,Evidence and interviews indicated facility failure to provide Resident #1 adequate pressure sore care and services resulting in Resident #1 sustaining skin injury.,2,0,Substantiated,Substantiated,Neglect +GP121877,385064,NF,12/5/2012,Evidence and interviews indicated facility failure to ensure Resident #1 did not sustain a loss of dignity as result of the 12/5/2012 incident with RP2.,2,0,Not Substantiated,Substantiated,Neglect +GP121948,385064,NF,12/17/2012,"The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 received adequate toileting assistance on 12/17/2012. All five residents were dependent on care assistance for transfers and toileting. The facility failed to ensure adequate toileting assistance resulting in Resident #1 experiencing a loss of dignity as well as emotional and physical discomfort. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 did not receive appropriate toileting and incontinence care on 12/17/2012. This failure is considered neglect of care and constitutes abuse.",2,500,Substantiated,Substantiated,Neglect +OR0000801200,385064,NF,1/3/2013,Evidence and interviews indicated the facility failed to ensure staff #3 followed professional standards of practice related to care planned fall interventions for Resident #1. Staff #3 failed to review Resident #1's plan of care prior to assisting Resident #1 to bed on 12/30/2012. Resident #1 was care planned for bed sensor alarm and staff #3 failed to ensure a bed sensor alarm was when assisting Resident #1 to bed. Resident #1 was found lying on her/his back on the floor 30 minutes after staff #3 had assisted Resident #1 to bed. Resident #1 sustained a left hip fracture as a result of her/his 12/20/2012 fall. Federal civil penalty recommended; relevant portions of the survey complaint report are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000808300,385064,NF,1/30/2013,Evidence and interviews indicated faculty failure to ensure Resident #1 received adequate skin care resulting in Resident #1 developing a pressure ulcer. This failure is considered neglect of care and constitutes abuse.,2,300,Substantiated,Substantiated,Neglect +GP121372,385064,NF,10/22/2012,"Evidence and interviews indicated facility failed to protect Resident #1 from RP2 (CNA) sexually abusing Resident #1. In addition, evidence and interviews indicated RP2 provided Resident #1 with care services in a rough manner resulting in Resident #1 sustaining pain. These failures are considered violations of resident rights, considered neglect of care, and constitute abuse. + + + +*Amended Complaint Report completed on 09/18/2014, complaint report findings of facts were changed to inconclusive regarding allegation of inappropriate sexual contact by RP2. Evidence and interviews from amended report indicated facility failure to ensure Resident #1 was provided adequate hygiene assistance by RP2.",2,,Inconclusive,Substantiated, +GP147331,385064,NF,6/8/2014,"Evidence and interviews indicated facility failure to provide a medication administration system that prevented the loss or theft of (1) care of 30, one-half tabs of Resident #1's prescribed narcotic pain reliever. Witness #4 (licensed nurse) indicated she/he gave a medication cart keys to other facility staff who were not within the line of sight of witness #4 while potentially accessing medication cart where Resident #1's narcotic pain medications were stored. The Facility failure to provide a medication system that prevented the theft or misuse of Resident #1's narcotic pain medication is a violation of resident rights are considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +OR0000675900,385068,NF,3/15/2011,"Staff failed to responded in a timely manner when Resident 1 took another resident's medication card(s) from an unlocked/unsupervised medication cart. Neither W2 or staff 5 promptly reported to Resident 1's physician, the DNS or RCM that Resident 1 took the cared(s) and possibly ingested the medication. Resident 1 denied taking the pills. Resident 1 was not monitored or placed on alert. Resident 1 was sent to the hospital for bleeding from a surgical site and from areas of self scratching. At the hospital Resident 1's INR was over the limits. W2 acknowledged not locking the cart properly. All staff working the weekend of the incident were disciplined and educated. Relevant portions of the survey are attached. A civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000675901,385068,NF,3/15/2011,The facility failed to store medication in a locked compartment that was not accessible to unauthorized personnel and or residents. Resident 1 required hospitalization for treatment of excessive bleeding as a result of taking and ingesting Coumadin from an unlocked medication cart. Relevant portions of the survey are attached. A civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +BC120780,385068,NF,8/3/2012,"RV did not receive Allopurinol for two days. RP2 signed for, but failed to dispense Allopurinol on 8/3, 8/4/ & 8/5/2012. Other staff caught the error and gave RV medication later on 8/5/2012. RV did not sustain notable negative outcome. RV's physician was not notified of the medication error in a timely manner; notified 8/9/2012. The facility requested RP2 receive additional medication administration training.",2,0,Not Substantiated,Substantiated, +OR0000815100,385068,NF,3/1/2013,Resident 1 was admitted 12/12/2012 with multiple diagnoses. The resident was to receive Prednisone per physician orders. The Prednisone was stopped without sufficient staff follow-up with the physician. The resident was sent to the hospital on 2/27/2013 with a discharge diagnosis related to adrenal insufficiency due to stoppage of the prednisone. The resident sustained harm constituting abuse. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.,3,0,Substantiated,Substantiated,Neglect +BC147972,385068,NF,7/29/2014,"Evidence fails to establish physical abuse; RP2's reporting of ""blocking"" RV's strike is reasonable. RP2 did not use derogatory language to describe RV, but RP2's language is definitely not appropriate around residents. RP2 failed to honor RV's choice in allowing RV to brush his/her own hair. Oregon Administrative Rule violation.",2,,Not Substantiated,Substantiated, +BC148175,385068,NF,7/28/2014,"RV2 reported RV1 kept saying I am going to kill RV1 ""so I sort of messed with RV2"". RV2 denied holding a knife to RV1. RV1 reported being roommates with RV2 and after moving from the room RV2 held a knife to RV1. W1 and 2 deny hearing anything about a knife, but both reported sequintiallyrv2 tends to bull; and RV1 sought out RV2 and harassed RV2. W2 indicated RV2 is on a waiting list for a specific setting. W4 reported RV2 became upset when RV2 did not get to move. W5, 6 and 7 reported RV2's behaviors around RV1 upset RV1. RV2's care plan was not updated until 7/30/2014 placing RV1 at further risk. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000911700,385068,NF,7/29/2014,"Resident 1 was a long term resident of the facility. Resident had multiple diagnoses including osteoporosis. Multiple staff knew of resident's swollen knee, but failed to ensure the physician was notified timely; failed to place resident on alert charting; and failed to follow-up on the knee issues. The resident physician was called 7/28/2014 and a subsequent x-ray found a fracture. The resident received scheduled pain medication, as well as, PRN pain medication prior to the 7/25/2014 the swollen knee finding on 7/25/2014. The resident was at risk for further harm due to untimely reporting of the resident change of condition. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000657700,385072,NF,12/28/2010,"Resident 1's 9/21/10 Initial Data Collection Form, the September 2010 MAR and the front chart allergy sticker revealed allergy to medications including amoxicillin and penicillin. Resident 1 received 6 doses of Augmentin (a penicillin) between 9/27/10 and 9/30/10. Resident 1 developed a rash requiring treatment and Resident 1's anticipated surgery for a leg fracture was postponed due to the ""significant adverse drug reaction in the form of a rash"". Multiple staff were involved in the medication error and failure to clarify the medication order before administering the medication. Additionally the facility allowed non-licensed staff to pull medication from the emergency box. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000681700,385072,NF,4/11/2011,"Resident 1 was admitted in March 2011 with multiple diagnoses and a history of hyperkalemia (blood levels of potassium, an electrolyte) which may require treatment. Resident 1 was receiving TPN with pharmacy to adjust the electrolytes. On 4/1/2011 at 12:55 P.M. the facility received lab results indicating critical high levels of potassium and phosphorus. Staff 3 faxed the lab results to the physician and pharmacy at 1:00 P.M. Staff 3 reported he/she faxed the lab results, but over looked the critical high results because they are usually circle/initialed by the lab. Staff 3 did not call the DNS or the physician. The lab and pharmacy telephone Staff 3 at 2:00 P.M. regarding the high levels, gave orders to stop the IV TPN and begin other IV treatment. Staff 3 ended the work shift without making arrangements for other staff to follow-up with Resident 1's physician. Staff 2 reported that facility staff could not rely on a fax notification at a busy physician office for critical labs, etc. to gain immediate physician attention. Prompt treatment and monitoring of the critical high potassium and phosphorus would likely have mitigated any serious effects and resulted in less trauma to Resident 1. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000718500,385072,NF,9/29/2011,The facility failed to establish an infection control program regarding Clostridium Difficile infection. The facility failed to provide evidence of all staff receiving education about CDI. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000729200,385072,NF,11/21/2011,"Resident 1 was admitted 2011 with diagnoses including diabetes. On 9/6/2011 Resident 1's physician ordered specific dressing changes to the Stage II left heel ulcer. On 11/13/2011 Staff 4 (LPN) cut away skin on the ulcer without a physician order or certification to provide sharp debridement. The ulcer size increased, treatment continued and the ulcer showed resolution. Resident 1's physician examined the ulcer on 11/17/2011 and found no adverse outcome to the ulcer, except size. Staff 6 reported RNs with certification may provide sharp debridement with orders, but LPNs can become certified. Staff were provided further in-service.",2,0,Not Substantiated,Substantiated, +OR0000793800,385072,NF,11/14/2012,"Resident 1 was admitted 2012 with diagnoses including a unstable comminuted left femur fracture and a below knee amputation. Resident assessment identified ADL needs and indicated risk for functional decline. The 11/15/2012 ADL CAA failed to include resident left leg immobilizer, etc. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000794600,385072,NF,11/15/2012,"Resident 4 was admitted 9/29/2012 following hospitalization. Resident 4 was admitted with a Foley catheter. The resident care plan indicated monitoring intake and output, urine characteristics, catheter care and referrals to specialty physicians, etc. Interviews and documentation found care was given as assessed and planned. Staff communicated with the resident's physician and provided care per physician orders including lab work and medication.",0,0,Not Substantiated,Substantiated, +OR0000862600,385072,NF,11/7/2013,"Resident 175 was admitted to the facility in 2013 with diagnoses including a UTI. Resident received Macrobid on 10-702013 for UTI and developed an allergic reaction. On 11/4/2013 Macrobid was again prescribed, medication was given and the resident developed an allergic reaction with a negative outcome requiring a hospital visit. Staff failed to transfer resident allergy information to the resident MAR and staff gave the Macrobid. The resident sustained negative outcome with a potential for great harm. Relevant survey information is attached. A federal civil penalty was recommended. Oregon Administrative Rule violations occurred..",3,,Substantiated,Substantiated,Neglect +OR0000862601,385072,NF,11/7/2013,"Resident 175 was admitted to the facility in 2013 with diagnoses including a UTI. Resident received Macrobid on 10-702013 for UTI and developed an allergic reaction. On 11/4/2013 Macrobid was again prescribed, medication was given and the resident developed an allergic reaction with a negative outcome requiring a hospital visit. Staff failed to transfer resident allergy information to the resident MAR and staff gave the Macrobid. The facility failed to maintain the resident's clinical record including sufficient information to identify resident allergies on all pertinent clinical records. The resident sustained negative outcome with a potential for great harm. Relevant survey information is attached. A federal civil penalty was recommended. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000879901,385072,NF,2/25/2014,"Resident 1 was admitted October 2013 with multiple diagnoses. Resident sustained a red/warm painful right hip on 2/20/2014, but family was not notified until 2/22/2014. the facility failed to promptly notify resident family of a significant change of condition. Relevant portions of the survey are attached. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000929400,385072,NF,10/28/2014,"Resident 1 was admitted 9/11/2013 with diagnoses including UTI. Resident received a dose of Macrobid to which the resident was allergic. Staff failed to recognize the allergy and alert the physician to the fact when the physician ordered the Macrobid. Unfortunately the resident's MAR did not contain the information, the medication was pulled and given to the resident. Staff notified the physician, administered treatment, called 911 and the resident was transferred to the hospital. The resident did sustain negative physical changes from the Macrobid. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +AL148860,385072,NF,6/21/2014,"The complainant reported RV's oxygen tank as running out on multiple occasions, the last time was 6/21/2014 resulting in RV's labored breathing and difficulty talking. Witnesses were aware of RV's oxygen tank running out and measures were adopted to prevent future occurrences. Despite measure being implemented RV's oxygen tank ran out again on 6/21/2014. the facility has taken new safety measures to ensure RV's oxygen tank will be changed when 1/4 of the tank remains and RV will be placed on the oxygen concentrator when RV is brought back from therapy. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES118459,385077,NF,11/8/2011,"RP2 admitted taking wound cream belonging to RV. The complainant sent pictures showing the cream RP2 had taken had RV's name and pharmacy on it. Whether or not RV was using the cream while in the facility, the wound cream prescription was the property of RV.",2,0,Not Substantiated,Substantiated,Financial abuse +OR0000856300,385077,NF,10/3/2013,Resident 1 was a long term resident with multiple diagnoses. Resident care plan of 9/11/2013 indicated a two person transfer using a gait belt. Staff 3 provided a one person transfer and lowered the resident to the floor. Resident sustained bruising. Staff 3 reported previous trainings of a one person transfer and had failed to read resident care plan. Staff 3 received written warning and verbal instruction. Staff now use work sheets for resident care. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000892700,385077,NF,4/23/2014,"Resident 1 was admitted January 2014 with multiple diagnoses. Resident care plan dated 1/21/14 indicated two person assist with multiple ADLs. On 4/21/2014 a one person slide board transfer was attempted, the board dropped as did the resident resulting a small scrape to the resident's left hand. While W1 failed to secure a second person to assist with the transfer, evidence is not conclusive the second person would have prevented the incident. W1 did fail to follow the resident's care plan. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred. All staff received further instruction regarding resident care plans.",2,,Not Substantiated,Substantiated, +ES147956A,385077,NF,7/28/2014,"RV reported not receiving pain medication timely; was in pain and had to go to the hallway to get help; and received medication at 11:00 P.M. The complainant did state the facility gave medication timely. RP2 discontinued any contact with the investigator and is no longer employed at the facility. Documentation review indicated RV received scheduled medication at 08:00 and 19:00 with pain levels at a 6 and above. On the night of the event RV's pain level was a 7 out of 10 at 19:16 and by 23:00 it was at a level of 10 of 10 by the time RV received the PRN medication. Evidence is inconclusive why RV did not receive medication timely, but the complainant reported it may have been due to a admission that day. Evidence is inconclusive for RP2's wrong doing given the number of admissions and possible increased work load. The facility failed to ensure RV received medications timely resulting in RV's increased pain. The facility failure constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES147900B,385077,NF,7/20/2014,RV's care plan was changed to two staff to provide personal care. The facility failed to ensure sufficient staff to provide prompt incontinence care for RV. Waiting extended periods of time for personal care represents neglect of care constituting abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +ES147979,385077,NF,7/30/2014,"RV and W5 reported RP2 said to RV something to the effect ""don't be a cry baby."" RP2 denies saying anything to this effect. RV complained of pain when RP2 repositioned RV. RP2 was ""abrupt"" and failed to treat RV with all due respect. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ES149688,385077,NF,12/22/2014,"W3 stated RV1 denied pain, but confirmed RP2 was ""rough""; ""RP2 turned RV too quickly"". W3 reported RP2 wanted more training; did not know the people very well. RV reported RP2 needed more training. Evidence supports RP2's lack of training. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000920402,385077,NF,9/9/2014,Resident 6 was admitted to the facility July 2014 with diagnoses including end stage renal disease. On 12/13/2014 resident did not receive all of his/her 8:00 A.M. medication. Staff 10 reported CMA was extremely busy and Staff 10 gave one medication he/she thought was most important. Staff 10 was not aware of resident's dialysis; resident did not receive all medication prior to resident appointment. The resident was at risk for harm. Relevant survey pages are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +ES149614,385077,NF,12/12/2014,The facility failed to ensure RV received timely toileting on occasion. RV reported missing two meals other than at the time RV was out of the facility. Documentation and witnesses noted RV did not receive and or documentation failed to record two meals. RV did receive snacks including sandwiches and RV maintained his/her weight. RV reported a long delay at least twice in receiving his/her pain medication. A delay in receiving timely oral pain medication would cause a longer period of discomfort for the resident. The facility failure to provide prompt care and services resulting in minor harm constitutes abuse. Oregon Administrative Rule violations occurred.,2,250,Substantiated,Substantiated,Neglect +ES150223,385077,NF,1/11/2015,RV was admitted to the facility on 12/13/2014 for rehabilitation. The resident arrived with physician ordered PRN pain medication; no scheduled pain medication was ordered. Due to the time frame from the initial complaint until interviews were obtained from witnesses and reported perpetrators most individuals do not recall RV. RP5 was able to recall having a conversation with RV regarding the difference between scheduled and PRN medication. RP4 and 5 report generally/normally gave requested medication within 5 to 15 minutes of the request. RP4 denied any remembrance of giving RV medication 119 minutes after a request. RV's journal and comparison to PRN medication pass record confirms repeated delay of RV's pain medication over days/time resulting in unnecessary discomfort and pain. The facility failure to ensure timely medication pass resulting in RV's unnecessary pain and discomfort constitutes abuse. Oregon Administrative Rule violations occurred.,2,300,Substantiated,Substantiated,Neglect +OR0000952102,385077,NF,3/5/2015,"The resident was admitted to the facility July 2014 with multiple diagnoses. The complainant reported the facility failed to apply dialysis port correctly. On 5/20/2015 W1 reported it was not the facility's responsibility, but the dialysis unit responsibility to place the port. An expanded resident sample did find Resident 5 and 6's care plan was not developed properly to address dialysis and associated care/treatment. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000952103,385077,NF,3/5/2015,Resident 1 was admitted July 2014 with multiple diagnoses including kidney disease. The resident's 7/21/2014 care plan indicated the resident had a pressure ulcer and documentation was to be completed per facility practice. The resident's July and August treatment documentation did not have documented treatment given. The pressure ulcer follow-up question report did not contain documentation after 8/6/2014the resident was discharged and readmitted without noted pressure ulcers until a 9/19/2014 assessment indicated readmission to the facility with two pressure ulcers. The resident's chart review found no measurement of the ulcers beyond 9/19/2014. the resident left and was readmitted on 1/24/2015 and again 3/16/2015 with pressure ulcers; again inadequate documentation monitoring and treatment. Relevant portions of the survey are attached. Enforcement action was proposed. A Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ES151823,385077,NF,6/26/2015,"RV reported RP2 ""got mouthy"" with RV getting ""louder and louder"" and not letting RV count to ten to calm down. RV reported RP2 pulled RV from the table startling RV; RV does not trust RP2. w4 reported telling RP2 that w4 did not like RP2 pulling RV from the table and RP2 brought RV back to the table. W4 does not remember RP2 ""yelling"" at RV. W5 reported RV was crying. RP2 reported being taught to "" pull them out of the crowd"", told RV to stop interrupting the activity and put RV back at the table. RP2 reported being unable to find his/her boss to talk to. RP2 denied RV was crying. Evidence is insufficient to support RP2 yelling at RV, but RV was not treated with all due respect. The facility failed to ensure all volunteers are properly trained on working with resident behaviors. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES150468,385077,NF,3/3/2015,"RP2 failed to follow RV's care plan for two person Hoyer transfer; transferred RV by RP2's self using the Hoyer. RV was care planned for a two person transfer to provide RV with comfort. RV reported telling RP2 regarding two people, but RP2 said only a one person transfer was going to be done. RV reports some discomfort and being upset. RP2 reported failure to read RV's care plan and stated RV did not say anything about two people until after RV was in the Hoyer. RP2 reported feeling it was unsafe to leave RV in the Hoyer to obtain another person's assistance. RP2 stated immediately reporting the incident. The facility took further action to ensure RV's comfort. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ES153349,385077,NF,10/22/2015,"Multiple RVs reported varied times for call light response. Resident 8 reported not liking to""pee on self"", but did not give call light time frame. W2 reported the general rule for response time is 10 minutes. RP2 reported staying over shift to assist residents. Call light response time was poor for at least RV2 and RV8 resulting in incontinence and or prompt incontinence care. The lack of prompt care constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES153051A,385077,NF,10/4/2015,"Per record review, resident (victim) interview and witness interview RP2 failed to administer pain medication as prescribed and requested by several residents. Reported victims number 5, 8, 9 and 10 describe requesting pain medication from RP2 and not receiving the pain medication resulting in increased pain. RP2 failed to properly document narcotic and anxiety medication for several residents placing residents at risk for harm. RP2 admits improper documentation of resident medication. RP2's failure to provide pain medication resulted in resident's increased pain which constitutes abuse through neglect of care. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Neglect +ES153051B,385077,NF,10/4/2015,RP2 directed direct care giving staff to make RV stay in bed when RV wanted to get up. RV was upset and became aggressive. RP2 obtained a physician telephonic order for an injection of anti anxiety medication and ordered staff to hold RV's arm. RP2's actions were in violation of RV's choice in treatment. RP2 used chemical restraint without trying other care plan interventions and RP2 used force/chemical restraint to seclude RV in RV's room. RP2's actions constitute abuse. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated,Neglect +OR0001028900,385077,NF,9/27/2015,"Resident 1 was admitted August 2015 with multiple diagnoses including septicemia. The resident's physician ordered Cerfazolin Sodium Solution 2 Gm IV every 8 hours times 8 days. The resident received the antibiotic for the midnight dose late at approximately 3:40 A.M. on 9/27 and at approximately 1:26 A.M. on 9/28/2015 so the next scheduled dose for 8:00 A.M. was given within 4.5 hours and 6.5 hours respectively. Staff 5 delivered both late doses of the antibiotic. The resident reported ""feeling"" nauseated, feet felt cold and got a headache when receiving the medication so close together. A pharmacy consult indicated the nausea was a common side effect independent of when the medication was given. Staff 5 did not notify the DNS or the physician the medication was given late or garner instructions regarding giving the 8:00 A.M. as scheduled. The resident was at risk for harm. The facility terminated Staff 5's employment and took further action involving the Oregon State Board of Nursing. Relevant pages of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000662100,385091,NF,1/19/2011,"Resident 1 was admitted 12/17/10 with multiple diagnoses including cognitive impairment and left total hip replacement. Resident 1 fell on 1/5/11 and sustained a right hip fracture. Staff 7 reported transferring Resident 1 to the wheel chair, but could not recall if he/she activated Resident 1's alarm. Staff 7 left the facility for the day, but told Staff 8 that Resident 1 was in the wheel chair. Resident 1 received medication at 2:00 P.M. shortly before being found on the floor at 2:40 P.M. Initially Resident 1 did not show signs of injury. Multiple staff were in contact with Resident 1, but all failed to ensure the alarm was activated. The facility initiated a new procedure of CMAs checking alarms when passing medication. Relevant portions of the survey are attached. A civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +MS116877,385091,NF,4/11/2011,"RV was admitted on 4/11/2011 with orders for an oral inhalation medication to be administered twice a day. RV did not receive an ordered medication from admission on 4/11/2011 through a 8:00 A.M. dosage on 4/26/2011. RV reported feeling worse and worse, complained of being very short of breath and feeling weak. W1 contacted the pharmacy, verified the medication was ordered, delivered and administered the medication beginning 4/26/2011. The facility failed to have an adequate procedure to ensure all ordered medication was obtained and administered to a resident. The facility failure to administer RV's medication in a timely fashion resulted in RV's deteriorating change of condition.",3,400,Substantiated,Substantiated,Neglect +MF128854A,385091,NF,1/6/2012,Staff failed to gain timely medical treatment for RV's rash. RV did not complain of itching or pain the rash did not worsen.,2,0,Not Substantiated,Substantiated, +MF128854B,385091,NF,1/6/2012,"Staff failed to ensure appropriate medication orders and medication accompanied RV to anew facility. The facility failed to ensure adequate policy/procedures were in place and or utilized to prevent inappropriate discharge medication orders and dispensing of medication. RV did not sustain harm, but was at risk for harm.",2,0,Not Substantiated,Substantiated, +MS132573,385091,NF,1/20/2013,"RP2 told RV that RP2 would ""pour"" urine on RV while giving personal care. RV reported RP2 left ""covers"" off RV and told RV that RV could do without care. RP2's verbal communication and lack of care towards RV constitutes emotional abuse. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +OR0000812800,385091,NF,2/21/2013,Resident 196 was admitted with multiple diagnoses. Resident assessment indicated a risk for skin issue and interventions were implemented. A 1/27/2013 progress sheet indicated the resident with a 3x3 cm area to the left heel; resident indicated the area occurred two days prior when he/she fell. New interventions included floating the resident's heels. On 1/31/13 a Stage II ulcer to resident's bottom was identified and care planned. The nursing notes dated 1/8/2013 through 2/6/2013 indicate multiple refusals of care. The reader is to note improper notification was found for Resident 200 on which this investigation was substantiated. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +MS132766,385091,NF,2/6/2013,"RV is dependent for transfer and is non ambulatory. Staff noted that noc shift beginning near midnight on 2/5/2013 and ending early on 2/6/2013 found a raised area above RV's right eye and marks along RV's chin, right hand and left shoulder. RV is unable to give relevant information. The facility was unable to determine which staff assisted RV to bed or the origin of RV's injuries. The facility failed to ensure a safe environment resulting in RV's injuries. This failure constitutes abuse and a Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +MS133366,385091,NF,4/23/2013,"Witnesses reported RV as an accurate reported. Witnesses give conflicting information regarding RP2 and his/her interaction with RV and other residents. RV reported RP2 ""yelled"" at RV and was ""demeaning"". RP2's written statement and employee discipline form give conflicting information. RP2 did fail to give RV a choice in care by having RV use a bed pan. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000827900,385091,NF,5/6/2013,"Resident 1 was admitted April 2013 following a total right knee replacement. Staff 8 gave resident Ativan instead of Dilaudid at 2:30 A.M. on 5/2/2013, but did not discover the error until 6:50 A.M. narcotic count. Resident physician was notified, but resident family was not informed. The resident sustained confusion and a fall resulting in a hip fracture. The facility failure constitutes neglect of care. Relevant portions of the survey are attached. A federal civil penalty was recommended. An Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +OR0000827901,385091,NF,5/6/2013,"Resident 1 was admitted April 2013 following a total right knee replacement. Staff 8 gave resident Ativan instead of Dilaudid at 2:30 A.M. on 5/2/2013, but did not discover the error until 6:50 A.M. narcotic count. Resident physician was initially notified, but resident family was not informed. While Staff 9 was checking on the resident every 30 minutes, Staff 9 failed to report increased lethargy and shallow breathing. The facility failed to increase monitoring and notify the resident physician of the increased change of condition. The facility failure constitutes neglect of care. Relevant portions of the survey are attached. A federal civil penalty was recommended. An Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +OR0000827902,385091,NF,5/6/2013,"Resident 1 was admitted April 2013 following a total right knee replacement. Staff 8 gave resident Ativan instead of Dilaudid at 2:30 A.M. on 5/2/2013, but did not discover the error until 6:50 A.M. narcotic count. Resident physician was initially notified, but resident family was not informed. While Staff 9 was checking on the resident every 30 minutes, Staff 9 failed to report increased lethargy and shallow breathing. The facility failed to increase monitoring and notify the resident physician of the increased change of condition. Staff observed the resident attempting to walk on his/her right leg; assisted the resident to the toilet and back to bed approximately fifteen minutes prior to the resident falling and sustaining a fractured hip. The facility failed to provide a safe environment resulting in receiving the wrong medication and sustain a fall with injury. The facility failure constitutes neglect of care. Relevant portions of the survey are attached. A federal civil penalty was recommended. An Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +OR0000826800,385091,NF,4/30/2013,"Resident 2 was admitted June 2010 with diagnoses including dementia. The facility failed to implement policy and procedure regarding incident occurrence reporting/response for one of one sampled resident (#2). Staff 2 reported ""grabbing"" Resident 2's wrist as resident attempted to scratch Staff 2. staff 2 heard a ""cracking"" sound as resident pulled away from Staff 2. staff 2 failed to inform the licensed nurse that Resident 2 complained of pain or the ""cracking"" sound as resident pulled away from Staff 2's grip on resident's wrist. Staff 2's ""grabbing"" Resident 2's wrist causing resident to react and sustain harm constitutes abuse. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Inconclusive,Substantiated,Physical Abuse +OR0000865401,385091,NF,12/3/2013,"Resident 1 was admitted November 2013 following a fall at home. The resident came in with multiple diagnoses. Resident's care plan identified needs and risk. The resident received medication that may contribute to constipation. The resident received Senna two tablets at bed time except on 11/21/2013. Resident's physician ordered daily MOM, but it was skipped for two days. Resident received daily Mira lax from 11/26 through 11/30/2013. The resident did not receive a bowel assessment and appropriate interventions resulting in the resident going for 8 days without a bowel movement. The resident received a suppository and enema day 7 and 8, but required further intervention. Staff failed to promptly assess and notify resident's physician of resident's change in bowel condition. Relevant survey pages are attached. Enforcement action was taken. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +MS145683,385091,NF,10/1/2013,"RV requested assistance with constipation. RP2 notified the licensed nurse (W5) who gave RP2 permission to assist RV in expelling stool. RV reported during the process RP2's finger entered RV's vagina; stroked RV. RP2 reported RV jumped and came down with RP2's finger entering RV's vagina. RP2 reported removing his/her finger and apologizing to RV. RP2 reported telling the nurse, although W5 does not recall this; W5 added caring for 18 patients and three new admissions that shift. RP2 and W5 received counseling regarding improper nurse delegation and working out of scope of practice. Evidence is inconclusive for sexual abuse given the evidence available at this time. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000896703,385091,NF,5/14/2014,"Resident 1 was admitted 2014 with diagnoses including diabetes and renal failure. The facility failed to ensure physician orders for sliding scale insulin were followed. Resident 1 received incorrect amounts of insulin on various dates in April, May and June. Resident was placed at risk for harm. Relevant pages of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000897504,385091,NF,5/16/2014,"Resident 4 was admitted 8/7/2013 with multiple diagnoses including diabetes. W1 reported the facility failed to check resident's CBGs. Resident's physician orders dated 8/8/2013 included checking resident CBGs before meals and at bed time for one week. The resident's physician order dated 8/15/2013 revealed CBGs were to be checked. The resident's progress record noted resident concern the CBGs were not being checked, staff contacted the physician and the physician ordered to check CBGs twice per day at resident request. Record review for October 2013 through July 2014 revealed resident CBGs were periodically checked. Additional resident records were checked and a deficient practice was found. Relevant portions of the survey are attached. Enforcement was suggested. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000903100,385091,NF,6/19/2014,"Resident 3 was admitted 6/12/201 with diagnoses including a right hip replacement. On 6/13/2014 during transport by Staff 5 Resident 3 dropped his/her feet resulting in increased right leg pain. Foot rests were not used on the wheel chair during the transport as staff stated having weighed the resident without the foot rests attached to the chair. Staff 5 had not checked resident's care plan prior to the transport. The resident was transferred to the ER for evaluation and treatment; a new fracture was discovered. Resident's care plan was not completed; and no indicators were found as to resident transfers and transport. Staff 5 failed to follow standard of care when not reading the resident's care plan, but the facility failed to adequately care plan for resident's safety resulting in injury which constitutes abuse. Relevant portions of the survey are attached. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +MS150080A,385091,NF,1/30/2015,RP2 failed to correctly identify RV and gave RV an additional BCG test along with another resident's medication. RP2 reported staff shortage of Certified Medication Aides; and not being familiar with residents; no photo in the medication book; asking RV if RV was the resident in question rather than checking the resident's wrist band; and feeling remorse RV had to sustain additional finger sticks to check RV's blood sugars. RV did not experience negative physical effects from receiving the wrong medication. RP2 quickly identified the error and provided prompt appropriate action. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +MS150080B,385091,NF,1/30/2015,The facility failed to ensure medication documentation/transcription was accurate regarding RV's medication A and B. RV received medication A in the A.M. instead of nightly for three days as RV's physician ordered. RV did not sustain adverse effects. RV received medication B once a day instead of twice per day as ordered from 1/27/2015 to 1/27/2015. RV was at risk for increased eye pressure. Evidence was insufficient to correlate the lack of medication B to RV's red eye of 1/22 015. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +MS146287,385091,NF,3/7/2014,"RV received if any minute amount of Zosyn IV. The error was immediately reported to the DNS and RV's physician. RV's PICC line was flushed, the IV tubing was disconnected, a new IV line was added and RV received the correct antibiotic. While RV was at risk for harm, RV did not sustain any notable effect. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000980100,385091,NF,7/9/2015,"Resident 70 was admitted 2010 with multiple diagnose including chronic generalized pain, dementia and stroke with left sided weakness. The resident's MDS dated 4/13/2015 revealed cognitive impairment and need for a two person transfer. On 6/30/2015 Staff 11 attempted a one person transfer, the resident's wheel chair moved and the resident was lowered to the floor. A later x-ray noted a left femur fracture which could have been caused by metastatic disease. Staff 11 indicated he/she had not seen the resident IRCP before transferring the resident. Staff 11 reported resident's legs moved the wheel chair and Staff 11 lowered the resident to the floor. The resident received pain medication and care plan changes to use of Hoyer for transfer. All staff received further in-service on the importance of checking the IRCP before providing any care. Relevant portions of the survey re attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +MS153678,385091,NF,11/17/2015,"Record review and interview indicates that on or about 6:00 A.M. 11/17/2015 RP2 repeatedly placed two fingers in RV's vagina and ""massaged"" RV's clitoris while asking RV ""do you like that"" and ""did that feel good."" RV reported a ""burning sensation"" after the incident, but no pain during the event. RV reported being sure RP2 was not cleaning RV or applying cream when RP2 was massaging RV's clitoris or inserting RP2's fingers into RV's vagina. RV and witnesses report RV was alert; had not received anti-anxiety medication since 11/16/2015 at 7:39 P.M. The facility promptly suspended RP2, but failed to immediately report the suspected sexual abuse to law enforcement. The preponderance of evidence supports RP2 inappropriately/sexually touching RV's vagina and clitoris. RP2's actions constitute sexual abuse. Oregon Administrative Rule violation occurred.",3,,Not Substantiated,Substantiated,Sexual abuse +OR0000694000,385104,NF,6/15/2011,"On 6/24/2011 RP2 said she/he wanted to put Resident #1 back in bed and RP2 was unable to find anyone to assist. When RP2 was unable to find anyone to assist she/he went on a break without telling anyone Resident #1 was alone sitting in a wheelchair, unsupervised. Resident #1 was found face down on the floor; she/he sustained two lacerations on the forehead and a 6.0 cm skin tear on the left arm. Federal penalty recommended; relevant portions of the survey report are attached.",3,0,Not Substantiated,Substantiated,Neglect +OR0000699900,385104,NF,7/15/2011,"Evidence and interviews indicated facility failed to provide adequate care and services regarding Resident #1's 7/15/2011 fall resulting in Resident #1 sustaining injury requiring hospital treatment. Federal penalty recommended, relevant portions of the survey are attached.",3,0,Substantiated,Substantiated,Neglect +OR0000703400,385104,NF,7/28/2011,"Evidence and interviews indicated facility staff failed to provide adequate care and services regarding Resident #1's fall on 5/13/2011. Resident #1 sustained a laceration of the right arm. Resident #1 was transported to a local hospital emergency room, returning to the facility with orders to change a right arm dressing daily.",2,0,Substantiated,Substantiated,Neglect +DL116120,385104,NF,1/6/2011,Evidence and interviews indicated facility staff failed to adequately communicate necessary information regarding Resident #1's care. The facility failure to adequately communicate necessary information regarding Resident #1's care resulted in a potential risk of moderate harm.,2,0,Not Substantiated,Substantiated, +DL118310,385104,NF,10/26/2011,Evidence and interviews indicated facility failure to ensure Resident #1 received adequate care regarding care planned interventions resulting in Resident #1 experiencing increased leg pain.,2,0,Substantiated,Substantiated,Neglect +DL129180,385104,NF,1/14/2012,Evidence and interviews indicated facility failure to ensure a safe environment for Resident #1. Resident #1 eloped from the building on 01/14/2012. Resident #1 was not dressed appropriately for the 35 degree temperature.,2,0,Not Substantiated,Substantiated, +DL129318,385104,NF,2/13/2012,On 02/13/2012 RP2 (CNA) provided Resident #1 one-person transfer assistance from bed to wheelchair. Resident #1 was care-planned for two-person transfer assistance. Evidence and interviews indicated RP2 failed to follow Resident #1's care plan for transfers.,2,0,Not Substantiated,Substantiated, +DL129779,385104,NF,4/11/2012,Evidence and interviews indicated facility failed to assure Resident #1 was safe on 04/11/2012. Resident #1 left the facility via the front door unaccompanied.,2,0,Not Substantiated,Substantiated, +DL120121,385104,NF,5/19/2012,Evidence and interviews indicated facility failure to provide Resident #1 with a safe environment resulting in Resident #1 exiting facility grounds via an unlocked gate on 05/19/2012.,2,0,Not Substantiated,Substantiated, +DL120127,385104,NF,5/22/2012,Evidence and interviews indicated facility failure to provide a safe environment for residents. A 05/28/2012 resident to resident altercation resulted in Resident #3 sustaining injury.,3,400,Substantiated,Substantiated,Neglect +OR0000747600,385104,NF,3/1/2012,Evidence and interviews indicated the facility failed to provide adequate care and services regarding Resident #27's 02/14/2012 fall with injury. Relevant portions of the survey complaint report investigation are attached.,2,300,Substantiated,Substantiated,Neglect +OR0000761400,385104,NF,5/10/2012,Evidence and interviews indicated facility failed to provide adequate care and services to prevent Resident #1's 5/5/2012 fall with injury. Relevant portions of the complaint report investigation are attached.,2,300,Substantiated,Substantiated,Neglect +DL120564,385104,NF,7/17/2012,Evidence and interviews indicated facility failure to provide sufficient staffing to provide adequate care for Resident #1on 07/17/2012.,3,400,Substantiated,Substantiated,Neglect +OR0000770300,385104,NF,7/2/2012,Evidence and interviews indicated facility failure to thoroughly investigate Resident #1's 03/28/2012 non-injury fall. Relevant portions of the survey complaint report investigation are attached.,2,300,Not Substantiated,Substantiated,Neglect +OR0000771000,385104,NF,7/9/2012,Evidence and interviews indicated facility failure to ensure care-planned fall interventions were in place when Resident #2 rolled from her/his wheelchair to the floor on 06/23/2012 sustaining injury. Relevant portions of the survey complaint report investigation are attached.,2,300,Substantiated,Substantiated,Neglect +OR0000772800,385104,NF,7/19/2012,Evidence and interviews indicated facility failure to complete an assessment for the use of self-releasing seat belt for Resident #3 who had seat belts. Evidence and interviews indicated facility failure to ensure care planned pressure alarms and fall mats were in place when Resident #3 sustained a non injury fall. Relevant portions of the survey complaint report are attached.,2,0,Not Substantiated,Substantiated, +OR0000774600,385104,NF,7/26/2012,Evidence and interviews indicated facility failure to ensure care-planned fall interventions were in place when Resident #5 sustained a fall with injury on 07/21/2012. Relevant portions of the survey complaint report investigation are attached.,2,300,Substantiated,Substantiated,Neglect +DL121500,385104,NF,11/2/2012,Resident #1 had a history of exit seeking and resided in a locked wing of the facility. On 11/2/2012 Resident #1 left a locked yard outside the facility without assistance. Resident #1 was found by witness #2 (facility staff) walking on the sidewalk outside of the facility. Facility failed to ensure Resident #1 did not leave the facility unassisted.,2,0,Not Substantiated,Substantiated, +DL121375A,385104,NF,10/20/2012,"On 10/20/2012 RP2 (CNA) assisted Resident #1 with getting up and getting dressed. Resident #1 became upset, flailed her/his arms while resisting RP2's attempts at providing care assistance. W1 (facility staff) directed RP2 to step out of Resident #1's room and allow Resident #1 time to calm down. Later that morning Resident #1 was found to have a 1.5 cm skin tear on her/his right forearm. Facility failure to ensure Resident #1 was safe resulting in Resident #1 sustaining a skin tear is considered neglect of care and constitutes abuse.",2,0,Substantiated,Substantiated,Neglect +DL121375B,385104,NF,10/20/2012,Evidence and interviews indicated facility failed to ensure adequate fall prevention care planning interventions were implemented for Resident #1. Resident #1 was known to be at high risk for falls and care-planned for two-person assistance with transfers. On 10/20/2012 Resident #1 self-transferred to her/his wheelchair. Facility failure to ensure adequate care plan interventions were in place is a violation of Oregon Administrative Rules.,0,0,Not Substantiated,Substantiated, +DL132013,385104,NF,12/30/2012,"Evidence and interviews indicated facility failed to assure timely pain medication administration for Resident #1. The facility failure to adequately administer Resident #1_x001A_s pain medication resulting in Resident #1 experiencing ongoing pain and delayed pain medication administration are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +DL132733,385104,NF,2/20/2013,Evidence and interviews indicated facility failed to ensure adequate care planning for Resident #1's hydration needs. Facility failed to ensure Resident #1 had adequate hydration placing Resident #1 at risk for dehydration.,2,0,Not Substantiated,Substantiated, +OR0000808800,385104,NF,1/31/2013,Evidence and interviews indicated facility failure to obtain a physicians order for wound care for Resident #2; facility failure to obtain clarification from the physician before reinstituting wound care orders that were in place prior to hospitalization; facility failure to arrange for Resident #2 to be seen by a wound care specialist for an arterial ulcer prior to discharge; Resident #2's ulcer increased in size. Federal penalty recommended; relevant portions of the complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000809500,385104,NF,2/4/2013,Evidence and interviews indicated facility failure to provide Resident #1 bowel care services according to physician orders resulting in Resident #1 requiring hospital treatment. Federal penalty recommended; relevant portions of the complaint report survey are attached.,3,0,Substantiated,Substantiated,Neglect +DL132581,385104,NF,3/6/2013,"Resident #1 a known elopement risk eloped from the facility on 03/06/2013. Construction workers were moving tools from the outside secure area and had left the gate open. Resident #1 was found about a block away from the facility within a short time of leaving the facility unescorted. Resident #1 was assessed and was not found to have any injuries. A new elopement assessment was completed for Resident #1, care plans were updated, staff were provided inservices and motion sensor alarms were added to exit doors.",2,0,Not Substantiated,Substantiated, +DL133100,385104,NF,4/30/2013,Evidence and interviews indicated facility failure to adequately intervene with Resident #1's behaviors toward Resident #2 resulting in Resident #2 becoming uncomfortable with Resident #1's ongoing behaviors toward her/him. These failures are considered neglect of care and constitute abuse.,2,,Substantiated,Substantiated,Neglect +DL117964,385104,NF,9/9/2011,"Evidence and interviews indicated Resident #1 was care planned for two-person transfer assistance using a Hoyer lift. However, facility staff were providing Resident #1 transfer assistance using a Sara lift. Facility staff were assisting Resident #1 with transferring using a Sara lift, Resident #1's arm scraped against the doorframe and she/he sustained two skin tears.",2,,Not Substantiated,Substantiated, +DL132371,385104,NF,1/22/2013,Evidence and interviews indicated facility failure to ensure facility staff provided Resident #1 timely assistance with care planned needs.,2,,Not Substantiated,Substantiated, +DL134635,385104,NF,10/6/2013,"Evidence and interviews indicated facility failure to provide Resident #1 timely assistance with toileting resulting in Resident #1 wetting her/his bed and sustaining being wet with urine in bed for and sustaining unreasonable discomfort. The facility failure to ensure timely assistance with toileting resulting in Resident #1 sustaining unreasonable discomfort are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +DL132861,385104,NF,3/30/2013,"Resident #1's care plan indicated she/he had, ""...potential for aspiration when eating too fast; serve food in separate bowls given 1 at a time to decrease eating too fast; cue [Resident #1] to slow down when eating"" On 03/30/2013 and 03/31/2013 Witness #2 and Witness #3 said RP2 (CNA) failed to follow Resident #1's care plan by offering Resident #1 all of her/his food at the same time and telling Resident #1 to ""...take one bite and put [her/his] hands in lap and if [Resident #1] didn't do what [she/he] was told [Resident #1] would not get pie...""",2,,Not Substantiated,Substantiated, +DL117959,385104,NF,9/6/2011,"Evidence and interviews indicated facility failure to assure resident safety and implement timely interventions for Resident #1's behaviors related to a resident-to-resident altercation on 10/15/20111 where Resident #1 hit Resident #2 on the side of the head and scratched Resident #2 on the wrists. The facility failure to assure Resident #1 and Resident #2's safety resulting in Resident #2 sustaining injury are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +DL147262,385104,NF,5/31/2014,"Evidence and interviews indicated facility failure to assure Resident #1_x001A_s safety on 05/31/2014. Resident #1 had a history of exit seeking with thirteen attempts at exit seeking from 03/30/2014 through 06/02/2014. On 05/31/2014 at approximately 11:15 pm a facility employee completed work and while driving away, discovered Resident #1 several blocks away from the facility with her/his wheelchair stuck in a grate next to main roadway.",3,250,Not Substantiated,Substantiated, +DL159859,385104,NF,1/7/2015,"Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 when Resident #1 who was known to exit seek, exited the building via an unlocked, unalarmed gate from a secured area of the facility.",2,,Not Substantiated,Substantiated, +DL152619,385104,NF,8/22/2015,"Evidence and interviews indicated facility failure to ensure adequate administration of Resident #1_x001A_s scheduled pain medication on or about 8/23/2015. Facility failure to provide Resident #1 adequate pain medication administration resulting in Resident #1_x001A_s pain and suffering continuing is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,200,Substantiated,Substantiated,Neglect +DL153214,385104,NF,10/12/2015,Evidence and interviews indicated facility failure to protect and assure Resident #1's rights when RP2 (CNA) used her/his private cell phone to take pictures of Resident #1 singing. RP2 was aware use of her/his personal cell phone and social media to post pictures of Resident #1 on the Internet was a violation of facility policy.,2,,Not Substantiated,Substantiated, +OR0000997200,385104,NF,8/26/2015,"Evidence and interviews indicated facility failure to ensure adequate care and services related to Resident #3's change of medical condition. The facility failure to provide Resident #3 the necessary care and services related to Resident #3's change in medical condition, resulting in Resident #3 sustaining a serious decline in health, requiring hospitalization, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +OR0000997201,385104,NF,8/26/2015,Evidence and interviews indicated facility failure to ensure Resident #3's family and physician received timely notification regarding Resident #3's change in medical condition placing Resident #3 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001003900,385104,NF,4/14/2015,"Evidence and interviews indicated facility failure to ensure adequate (timely) response to Resident #3 and Resident #4's changes in medical condition and facility failure to ensure physician orders were implemented as ordered. In addition, evidence and interviews indicated facility failure to ensure Resident #4's records were complete and accurately documented. The facility failure to provide adequate response to Resident #3 and Resident #4's changes in medical condition, failure to ensure physician orders were implemented as ordered, and failure to ensure accurate record documentation is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0001003901,385104,NF,4/14/2015,"Evidence and interviews indicated facility failure to ensure Resident #4's pressure ulcer was properly assessed, monitored, and treated to prevent worsening of a pressure ulcer. The facility failure to provide Resident #4 adequate pressure ulcer care and services, resulting in Resident #4's wound becoming significantly worse, requiring hospitalization, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +OR0001003902,385104,NF,4/14/2015,Evidence and interviews indicated facility failed to ensure minimum CNA staffing ratios were maintained for four of 35 days reviewed. Facility failure to assure minimum CNA staffing placed facility residents at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +AL105646,385107,NF,8/30/2010,"Resident #1 had physician orders for pain narcotic every three hours as needed for pain. On 8/29/2010 Resident #1 was given pain medication. On 8/30/2010 Resident #1 asked medication aides for pain narcotic medication three different times between 12:45 am and 2:30 am. Resident #1 did not receive requested narcotic pain medication during the morning hours of 8/30/2010 and Resident #1 experienced ""bad pain.""",2,0,Substantiated,Substantiated,Neglect +OR0000681300,385107,NF,4/11/2011,Evidence and interviews indicated facility failed to provide Resident #1 the necessary care and services to prevent the development of a pressure ulcer. Federal penalty recommended; relevant portions of the survey report are attached.,3,0,Substantiated,Substantiated,Neglect +AL129258,385107,NF,12/30/2011,The facility failed to protect Resident #1 from RP2 (facility staff) financially exploiting Resident #1.,4,750,Substantiated,Substantiated,Financial abuse +AL121442,385107,NF,10/6/2012,"Resident #1's 9/17/2012 care plan indicated she/he required two-person assistance for transfers and a stand-lift for toileting on a commode. On 10/6/2012 Resident #1 asked for toileting assistance, hoping to obtain help using the commode. However, when RP2 assisted Resident #1 with toileting, she/he provided a bedpan instead of assisting Resident #1 to the commode.",2,0,Substantiated,Substantiated,Neglect +AL146702,385107,NF,11/7/2013,Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 and Resident #2 related to a resident-to-resident altercation on 11/07/2013. Resident #1 was overheard by facility staff yelling at Resident #2 and was observed to have kicked and hit Resident #2.,2,,Not Substantiated,Substantiated, +OR0000875000,385107,NF,1/28/2014,Evidence and interviews indicated facility failure to ensure Resident #1's insulin was administered with her/his meals placing Resident #1 at risk for low blood sugars. Relevant portions of the complaint report investigation are attached.,2,,Substantiated,Substantiated, +OR0000913900,385107,NF,8/8/2014,"Evidence and interviews indicated facility failure to provide Resident #1, Resident #2 and Resident #3 adequate catheter care. Evidence and interviews indicated facility failure to provide Resident #1 adequate catheter care related to Resident #1's change in medical condition. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +AL150141,385107,NF,6/15/2014,Evidence and interviews indicated facility failure to protect Resident #1 from exposure to inappropriate sexual content. On or about 6/14/2014 RP2 (CNA) showed Resident #1 pornography that was displayed on RP2's cell phone. RP2's conduct was a violation of the codes of conduct that apply to her/his professional license. RP2 received a reprimand for the Oregon State Board of Nursing for her/his conduct toward Resident #1 regarding this incident.,2,,Not Substantiated,Substantiated, +AL151899,385107,NF,10/13/2014,"EEvidence and interviews indicated facility failure to assure Resident #1 was safe related to circumstances on 10/11/2014. A 10/2014 care plan for Resident #1 indicated she/he was an elopement risk; she/he was care-planned for a Wander Guard. On or about 10/11/2014 Resident #1 left the facility unassisted and unknown by facility staff, she/he was located across the street from the facility late the same day.",2,,Not Substantiated,Substantiated, +OR0000663200,385112,NF,1/25/2011,"Resident 1 was found on hi/her room floor with a laceration to the left ear and a hematoma to the head. Resident 1 reported to staff his/her call light was no in reach. Staff determined his/her wheel chair alarm was not in place nor was he/she wearing the care planned lap buddy. Staff reported Resident 1 had wheeled self to his/ her room without their knowledge; lap buddy to be placed when in room alone. Staff 5 reported Resident 1 was in bed with tab alarm at the time of his/her fall, but staff 3 reported no alarm was sounding. Evidence remains unclear which staff may have failed to ensure Resident 1's care plan was followed, but Resident 1 did self transfer, fall and sustained an injury.",2,0,Substantiated,Substantiated,Neglect +OR0000674100,385112,NF,3/7/2011,"Resident 1 sustained a fall on 3/4/11. Resident 1's care plan was not followed at the time of the incident. Resident 1 required a lap buddy and an alarm while in the wheel chair. Resident 1 was not to be left unattended while in the wheel chair. Staff found Resident on the floor near his/her wheel chair; stated attempting to get out of bed. Staff reported assisting Resident 1 into the wheel chair, placing the alarm and forgetting to place the lap buddy. Staff 4 reported not being aware no to leave Resident 1 alone in the wheel chair in his/her room. Staff 4 reported he/she floated through out the facility and for got to review Resident 1's care plan. All staff involved with Resident 1's care received in-service and counseling for safety needs of residents, the importance of reviewing care plans and the use of personal safety devices. The RCM will audit compliance . Relevant portions of the survey are attached. A directed in-service was proposed.",2,0,Not Substantiated,Substantiated, +OR0000713400,385112,NF,9/6/2011,Resident 2 was admitted February 2010 in a permanent vegetative state. On 8/31/2011 Staff 3 (LPN) and Staff 9 (CNA) attempted to transfer Resident 2 using a Hoyer lift. Resident slid from the sling as it began to tip. Staff failed to ensure the lift and resident were stable. Staff believed the Hoyer legs could be open or closed during transfer. The resident sustained a scrape to the knee and later complained of pain. Subsequent x-ray did not reveal a fracture. Neither staff had attended a Hoyer transfer class that was given to clear the misconception regarding the Hoyer leg placement. At the time of the incident staff were in hurry to sit the resident up due to respiratory distress. Relevant information from the survey is attached. Facility enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000784000,385112,NF,9/14/2012,"Resident 1 was admitted to the facility on 9/8/2012 with multiple diagnoses. Resident 1 was found on the floor on 9/10/2012 not knowing how he/she fell. W3 assessed Resident 1 and sent Resident 1 to the hospital, but the assessment and transfer was not completed in a timely manner. W1 reported ""they had no sense of urgency"". W2 stated 911 was not called for two hours, which the hospital physician felt was too long. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000784200,385112,NF,9/17/2012,"Resident 2 was admitted 9/5/2012 with multiple diagnoses. Resident 2's care plan of 9/5/2012 indicated a fall risk with interventions including a low bed, non skid foot wear and call light within reach. Resident 2 was found on the floor on 9/7/2012 and 9/8/2012 without an alarm in place. Resident 2 began complaining of groin pain and a subsequent x-ray revealed a right hip fracture. Staff failed to ensure resident's alarm was in place to alert staff to resident getting out of bed on more than one occasion and falling. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure represents an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +BC132004,385112,NF,12/7/2012,"RV2 declined to be interviewed and RV1 was unable to be interviewed due to cognitive impairment. W1 reported moving RV1 and RV2 after RV2 was observed with his/her hand under RV2's shirt. W1 reported RV2 usually wears a undergarment beneath RV2's shirt. W2 reported RV2 had not displayed inappropriate behavior to this event other than hand holding, but W5 speaks of near ""misses""; uncertain what W5 means by this. W4 reported RV2 touched another resident's breast on 2/24/2013. W6 speaks of RV2's care plan of 11/4/2012 to be supervised around other females. Staff were within a few feet of RV1 and RV2, but due to wheel chair position did not observe RV2's behavior and or were not really observing RV2. staff failed to follow RV2's care plan and RV1's dignity was not up held when RV2 reached beneath RV1's shirt. The facility failure constitutes abuse and an Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +OR0000808001,385112,NF,1/30/2013,"Resident 1 was admitted 2010 with diagnoses including quadriplegia, traumatic brain injury and a tracheostomy. The resident's re-admission diagnoses also included a UTI, MRSA and chronic respiratory failure. Resident's Bactrim was to be discontinued after the 7th day, but the computer stop date did not register and resident received additional antibiotics without noted negative effect. Portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +BC133482,385112,NF,6/7/2013,"RP2 reported working quickly with RV as RV was agitated. RV was a one person transfer; care plan did not mention bed mobility. RP2 acknowledged pulling RV up in bed using RV's arms which would not be considered stellar standard of care. RP2 reported RV said ouch and RP2 apologized, but there was no evidence of injury at the time of the incident. RV's arm bruising developed 24 hours later. Evidence is inconclusive if use of a draw sheet was available or not. An Oregon Administrative Rule violation occurred.",2,0,Inconclusive,Substantiated, +BC134276B,385112,NF,8/24/2013,"RV and RP2 had a verbal interaction. RP2 left RV's room as the instructed, but returned to apologize after being told to stay out of RV's room. RV reported another person ( not RV ) heard RP2 say ""RV was crazy"". RP2 failed to treat RV with all due respect. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC135099,385112,NF,11/9/2013,Between 9:45 P.M. 10/9/2013 and approximately 7:00 A.M. 10/10/2013 RV's IPod and charger went missing from RV's room while RV was sleeping. The facility failed to provide accessible lock space for RV's belongings. RV's IPod and charger will be replaced by the facility. The facility will provide accessible storage. The facility failure to provide adequate storage resulting in disappearance of RV's IPod/charger constitutes abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Financial abuse +OR0000877603,385112,NF,2/13/2014,"Resident 1 was admitted 7/31/2013 with multiple diagnoses. Staff were to monitor resident's oxygen saturations and on 12/3/2013 resident 's saturation was 78%. Staff found the humidifier and O2 concentrator were not sealed properly. Resident reported no shortness of breath, staff corrected the problem and stayed with the resident until the oxygen saturation came back up. Staff had failed to ensure resident equipment was functioning properly placing resident at risk for harm. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC148717,385112,NF,9/22/2014,"RV's care plan indicates no care giver of the opposite sex and do not wake to provide care. RP2 and RP3 (one is of the opposite sex) reported entering RV's room to provide care, RV was awake and RV refused care, but then accepted care per RP2 as RV ""calmed down"". RP2, 3 and 4 all agree RP4 instructed RP2 and 3 to provide incontinence care to RV and not accept no from RV. RP4 reported W6 had told RP4 earlier to clean RV no matter what. RP4 is a fairly new licensed nurse and knew RV was to have same sex care givers, but had not been trained on the electronic system in order to review RV's complete care plan. The facility failure to properly train and or supervise RP4 resulted in staff providing care despite RV's protests. RV sustained significant loss of dignity and reported fear as staff continued to provide care. The facility system failure to ensure adequate training and supervision of their staff resulted in RV's emotional distress/fear which constitutes abuse. Oregon Administrative Rule violation occurred.",3,400,Substantiated,Substantiated,Neglect +BC150701,385112,NF,3/20/2015,"RP2 failed to transfer RV using RV's care planned two person gait belt transfer. W1 offered to obtain a gait belt, but RP2 declined the offer. W1 reported RP2 took RV's diaper off quickly; red marks were observed on RV's legs and RV was screaming it hurt the whole time RP2 continued to roll RV from side to side to clean RV's peri area. W1 reported RP2 + +moved RV so quickly to the bed that W1 was unable to undress the bed therefor no draw sheet was available to help move RV up in bed and RP2 left RV down in the bed with pillows while leaving the room saying he/she was done. W2 reported RV is a two person transfer using a gait belt, RV is ""stiff"" and does not like to be rolled. Further evidence was presented finding RP2 and W1 stood to either side of RV, RV was able to ""push self to stand"" and RP2 along with W1 guided RV by ""loosely"" holding RV's pants. No one immediately checked RV for marks and no one on the following shifts found any marks. RV has a history of calling out at times. RP2 continued to provide care on following shifts without RV providing any complaints. The facility administration took action to provide for resident safety, although it was somewhat delayed as W1 failed to promptly report RP2's actions. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Physical Abuse +BC152431,385112,NF,8/7/2015,"RV's PRN pain medication was delayed for an extended period of time resulting in RV's increased pain. Interview and documentation review indicated RV missed the 12:00 P.M. narcotic medication and then on return to the facility at 3:00 P.M. did not receive the requested PRN medication until 3:40 P.M. RV requested the 8:00 P.M. PRN medication, but RV's supply was out, the E box was out and staff were waiting for the order. W3 checked with RV at 8:00 P.M. and RV said he/she was ok, sleepy and was awakened for the schedule medication. W3 assured W1 at 9:00 P.M. the pain medication coming from the pharmacy would be given on arrival, but RV requested transport to the ER before the medication arrived. While the facility can not control RV's time at the physician office, the facility could have sent one dose of the PRN medication with RV. The facility failed to have an adequate supply of RV's pain medication and did not ensure the E box was adequately stocked. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +BC164788,385112,NF,2/20/2016,During a transfer staff failed to follow RV's care plan. RV slumped over and while sitting down and RV's arm struck the toilet commode arm causing a small skin tear to the left forearm. RV may have sustained the unforeseeable injury whether or not the two person transfer was performed. Staff received re-education to read and follow the resident care plan. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +KF129791,385115,NF,2/9/2012,"On 2/9/2012 RV attempted ambulation without assistance. While RV was sent for evaluation, no x-rays were taken at that time. Subsequent x-ray revealed a pelvic fracture. Staff failed to tell other staff RV was on the toilet, but RV had the call light and was reminded to use the call light. Staff reported in hind sight they should have alerted other staff that RV was on the toilet before they left the floor. Staff estimated RV's call light could not have been on for more than 14 minutes before RV attempted self transfer. W2 reported that RV's physician believed RV sustained a another CVA on 2/15/1; W2 reported believing RV's 2/9/ fall may have been related to a CVA, too. New pagers were obtained after this event when one CNA reported his/her pager never went off. The facility failed to ensure a safe environment existed including all pagers working properly. Evidence is no conclusive the pagers were functioning properly at the time of RV's fall. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +KF145981,385115,NF,1/31/2014,RV1 and RV2 have cognitive impairment with RV1 assessed as a wanderer. RV2 is independent with ambulation with a history of anger issues. RV2 struck RV1 as RV2 did not want RV1 in RV2's room. On 1/31/2014 W2 found RV1 in a resident's room; RV1 was found with skin tears to his/her face and arm. The facility failed to provide an adequate safe environment for RV1 and RV2. RV2's room now has a tape across the door. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +KF149691,385115,NF,12/22/2014,"RP2, W1 and W2 reported that as RP2 left the pantry area RP2 stated ""RV is just being an ass hole"". Unfortunately RV entered the same vicinity (nurses station) as RP2 and at the same time of RP2's comment. RP2 was unaware of RV's presence until RV stated ""yeah I'm an ass hole, and proud of it"". W3 noted the same day as the incident that RV denied ever being called a foul name or receiving mean treatment. RP2 admitted their error, showed remorse that RV heard RP2's comment, RP2 was placed on a two day leave without pay and will/did attend 8 hours of training in managing dementia resident behavior. An Oregon Administrative rule violation occurred.",2,,Not Substantiated,Substantiated, +KF151590A,385115,NF,6/13/2015,"The facility failed to properly train staff in a safe two person transfer for RV, as well as, failure to care plan for a safe Hoyer transfer. RV sustained pain during the transfer and a bruise to RV's finger. The improper transfer constituted neglect and resident injury. The facility failed to provide a safe environment constituting abuse. Staff received further in-service on RV's transfer needs. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +KF151590B,385115,NF,6/13/2015,"W6 reported RP2 stated she/he had to tell RV to stop making stuff up. RV reported RP2 ""raised his/her voice and said stop telling lies about me"". RV reported hurt feelings and embarrassment. RP2 reported and event with RV in which RP2 denied yelling at RV, but did tell RV to "" stop telling lies"". RP2 reported doing his/her job and does not speak to RV. RP2 failed to treat RV with all due respect. RP2 should be speaking to RV while providing care as a professional courtesy and to ensure the care is being provided as RV requests. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000977700,385115,NF,6/24/2015,"Resident 1 was admitted May 2015 with diagnoses including a stroke with left sided weakness. The resident's undated care plan indicated two staff were required for transfer, toileting and ambulation. The resident's MDS of 5/21/2015 indicated all staff and a 6/21/2015 progress note documented the resident ambulated with one staff and a use of a walker. On 6/22/2015 Staff 7 left the resident standing with his/he walker to go a few feet to get a wheel chair. Staff 5 was in the room, but staff were unable to prevent the resident from falling and hitting his/her head on the floor. The resident was transferred to the ER. Staff 7 readily admitted he/she should have placed gait belt on the resident and not left the resident's side even if he/she was only a few feet away. Staff reported staff did not always look at care plans, but depended on other staff information. Two other residents were reviewed and other issues were sited as indicated in the investigation. Relevant pages of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +KF153577,385115,NF,11/10/2015,"On 11/10/2015 RV sustained injury to RV's left forearm including skin tear and bruising after RP2 ""grabbed and twisted"" RV's left arm twice; once behind RV's back per W2. RP2 reported RV stood up, became angry, swung arms, was yelling and ""throwing"" punches. RP2 reported learning ""arm manipulation"". RP2 acknowledged causing RV's injury. RP2 stated not knowing RV's care plan which did indicate to change provider as an intervention to RV's behavior. RP2's behavior constitutes abuse by rough handling. The facility failed to train all staff regarding interventions with combative residents. The facility failed to ensure RV and all residents were in a safe environment in allowing RP2 to continue working after the alleged abuse of RV. As of 11/17/2015 RP2 was still actively working in the facility. Interview indicates RV is known to have aggressive behavior prior to facility admission and has become more aggressive. RV's care plan did not include staff are to walk away from RV when RV became irritated as noted in the 11/10/15 event although witnesses reported RV's increasing behaviors. The facility lack of staff training regarding combative residents, staff working 14 days straight without a break, failure to ensure only opposite gender staff provide care to RV and failure to keep alleged abusive staff from working contributed to RV's injury. Neglect of RV's care constitutes abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Physical Abuse +KF164856,385115,NF,3/2/2016,"RV attempted a self transfer from the toilet without requesting assistance and or using the call light. RV sustained a head injury requiring sutures and or staples. Per witness interview, direct investigator observation and documentation review RV showed confusion, required a one to two person assisted transfer and certain witnesses state RV should have had staff with the RV while RV was toileting. Review of RV's care plan before and after the fall event of 3/2/2016 does not contain staff direction to stay with RV when RV toilets. W3 was unaware RV required staff attendance with toileting and left RV alone after reminding RV to use the call light. The facility failed to adequately care plan for RV's safety resulting in RV's preventable injury fall. The facility failure constitutes neglect and abuse. Oregon administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +WB116052A,385117,NF,10/11/2010,"RV was unable to give relevant information due to cognitive impairment. W1 reported assisting RP2 when RP2 ""shoved"" RV back into bed. W1 and RP2 reported RV was being combative. RP2 would neither ""confirm or deny"" the allegation. RP2 stated it didn't happen how it was reported. RV's care plan of 8/17/10 directs staff to back off and re-approach RV if RV is resisting care. At minimum RP2 failed to follow RV's care plan to back off care when RV is resisting. RV was not injured. The facility took prompt intervention to ensure RV's safety.",2,0,Not Substantiated,Substantiated, +WB116052B,385117,NF,10/11/2010,"RV was unable to give relevant information due to cognitive impairment. W1 reported RP2 told RV that RP2 was going to ""kick RV's ass"". RP2 reported RV knocked the wind out of me. RP2 would neither confirm or deny the allegation and reported it did not happen as reported. W1 later reported over hearing RP2 ""venting"" about RV. RP2 referred to an incident report she/he completed, but was not found in the facility. RP2 failed to follow RV's care plan and back off care when RV is resistive to care. RP2 did make some form of verbal comment to RV; not conclusive it was a threat. Evidence does not support RV hearing RP2 "" venting"" about RV. RP2 failed to treat RV with all due respect.",2,0,Not Substantiated,Substantiated, +OR0000859001,385117,NF,10/22/2013,Staff failed to notify resident physician of resident change of condition; resident's increased temperature. Staff sent a fax on 10/14/2013 without actual resident temperatures and did not respond to documentation inquiries as to what a low grade temperature meant. Resident condition continued to change and staff called the physician. Staff failed to properly assess and promptly report resident changing condition. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rules were violated.,2,,Not Substantiated,Substantiated, +OR0000859002,385117,NF,10/22/2013,"The resident's family was not promptly notified of resident's changing condition until 10/12/2013 at 5:37 P.M. As the resident sustained further temperature and body aches, as well as, other changes on 10/14/2013 staff failed to promptly notify the resident family. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000859003,385117,NF,10/22/2013,"The resident was admitted on 9/30/2013. The resident contracted Listeria, but evidence is inconclusive as to how, when or where. Facility investigation identified significant weaknesses in tracking food temperatures and sanitation. This facility failure placed all residents in harm's way. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000859000,385117,NF,10/22/2013,Staff gave Resident 1 Tylenol when resident temperature increased with out a physician order. Staff failed to document resident changing condition or that Tylenol was given. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000880900,385117,NF,3/4/2014,"Resident 1 was admitted October 2013 with diagnoses including CVA with Right sided hemiplegia. Resident was care planned to have staff remove resident wheel chair foot rests prior to transfers. On 3/4/2014 resident sustained a skin tear to the leg when W1 swung the foot rests to the side, but did not fully remove the foot rests at time of transfer. Resident care plan had been implemented as one precaution due to the resident history of fragile skin and skin tears. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000966600,385117,NF,4/29/2015,"Resident 1 was admitted 4/15/2015 with multiple diagnoses including bacterial pneumonia, COPD and Chronic kidney disease. On 4/24/2015 at approximately 7:30 A.M. the resident sustained an unwitnessed fall. The resident reported, as identified in the Department note, he/she got up to use the bathroom and everything went blank. Shortly following this event the resident had an unresponsive episode and the physician office was called without documented response. On 4/24/2015 the resident sustained another event at approximately 8:00 P.M. and about 1:16 p.m. on 4/25/2015 started to become unresponsive . No documented evidence of consulting with the resident's physician regarding resident change was found. Additionally Staff 2, 3 and 12 failed to properly complete neurological checks, failed to ensure the resident's physician was consulted and failed to ensure an adequate assessment for injury/change of condition was completed. The resident was at risk for further harm. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violation occurred.",2,,Inconclusive,Substantiated, +OR0000995801,385117,NF,8/20/2015,Resident 78 was admitted July 2015 with diagnoses including CHF and chronic airway obstruction. Based on interview and record review Resident 78 was not promptly assessed by a facility nurse (wait of one hour and 27 minutes) for a reported change of condition. EMS was not contacted for 56 minutes and then only at request of resident's spouse. When paramedics arrived the resident required emergency treatment and transport to the hospital. Once at the hospital the resident required intubation and placement on a ventilator. The resident did not recover and died in the hospital. The facility failure to provide prompt assessment and response and documentation to the resident's condition changed resulted in delayed transfer to the hospital for evaluation and treatment. The facility actions resulted in neglect of care which constitutes abuse. Relevant portions of the survey are attached. Enforcement and sanction imposed by CMS. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +ES105978,385120,NF,12/22/2010,"RP2 admitted inappropriate touch of RV's peri area. Witness observed RP2 with hand inside RV's brief; rubbing back and forth. Staff immediately intervened. RV did not express much if any reaction. Eugene Police and Senior and People with Disabilities were immediately notified. RP2's employment was immediately terminated. RP2 was arrested for sexual assault. The facility had no previous concerns regarding RP2. The facility policy for Activity staff was to "" always contact the CNAs for personal care"".",2,0,Not Substantiated,Substantiated,Sexual abuse +OR0000663000,385120,NF,1/24/2011,"The facility failed to ensure Resident 2,3, & 4 remained free of accidents, provide supervision and or that the care plan was followed. Resident 2 was admitted in 2005 with multiple diagnoses and assessed as a fall risk. Resident 2 sustained falls and the care plan was not updated at times, etc. Resident 3 fell and reported that therapy had suggested two CNAs for transfer, but there was no discussion found and no update to Resident 3's care plan prior to the 1/23/11 event. Resident 4's care plan was not accurate regarding use of a lap buddy. Enforcement action was suggested. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +OR0000663001,385120,NF,1/24/2011,The facility failed to have and implement adequate staffing on a number of occasions. Resident call lights were not answered in a timely manner. Resident 2 and 4 did not receive care planned baths for 11 days. Enforcement action was taken. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +ES105937,385120,NF,12/12/2010,"The facility failed to care plan RV's incontinence and/or use of an incontinence product. RV's nursing notes reflect continued use of an incontinence product with out appropriate assessment and care planning. RV reported to W3 and/or in the facility investigation that RV had attempted to use the bathroom via wheel chair, was pushed back, placed in a brief, assisted to bed, was unable to reach the wheel chair or call light and became incontinent. RP2 placed RV in an incontinence product, as staff had been using, but which was not care planned. RV's choice in care was not assessed or adequately care planned contributing to RV_x001A_s incontinence and loss of dignity.",3,300,Substantiated,Substantiated,Involuntary Seclusion +OR0000667600,385120,NF,2/9/2011,"On 01/23/11 Resident 1 was transferred to a local Emergency Department (ED) from the facility. While at the ED it was determined Resident 1 had consumed 100 to 120 tablets of pain medication in an effort to end his/her life, and Resident 1 was admitted to the hospital. On 02/01/11 Resident 1 was improving and was noted in a Social Work Care Management (SWCM) note that he/she could be discharged to a facility with continued care for his/her psychological condition. In another SWCM note from 02/04/11 a local hospital physician indicated Resident 1 was stable medically and from a psychiatric standpoint was appropriate for placement back at the facility. Despite this the facility determined Resident 1 was not able to return to the facility indicating Resident 1 needed inpatient psychiatric care. Resident 1 was issued a Notice of Denial of Readmission/Return back to the facility on 02/10/11. The facility denied re-admission to the resident for a total of 6 days, and Resident 1 was transferred to a different facility on 02/16/11. The facility failed to allow the resident their right of return from a hospital. + + + +This conduct constituted a violation of Oregon licensing rules. Relevant portions of the CCMU survey have been attached.",4,1500,Not Substantiated,Substantiated, +OR0000678002,385120,NF,3/23/2011,"W1 reported staff called on 3/14/11 stating Resident 1 needed to be discharged ""as soon as possible."" W1 reported family had not received written notice from the facility. Staff 2 reported the discharge was initialized by telephone following an incident between Resident 1 and Resident 7. Staff 1 reported no official notice would be sent if resident 's family was cooperative with a discharge. W2 had talked with staff about the need to send written notice. The facility failed to respect a resident's right related to a transfer request to move out of the facility. Relevant portions of the survey are attached. A directed in-service was requested.",2,0,Not Substantiated,Substantiated, +ES120117,385120,NF,5/20/2012,"RP2 was not on duty, but just arriving to work and helped transfer RV from a vehicle into a wheel chair. RV complained of pain under his/her arms/rib area. RP2 reported not wanting RV's family to have to wait for staff already on duty. A gait belt was not used as RP2 was not yet in the building and a gait belt was not readily available. For future resident safety, staff not on duty and without proper equipment to perform a safe transfer, should seek clear direction from licensed staff on duty.",2,0,Not Substantiated,Substantiated, +OR0000798800,385120,NF,12/17/2012,"Resident 1 was admitted 2012 with multiple diagnoses. Resident 1's in room care plan of 12/5/2013 indicated staff were to stay with the resident when the resident was in the bathroom. The investigator and this reviewer observed the care plan and noted illegible writing. Staff 3 reported not seeing the information to stay with the resident. Staff 3 could have questioned the care plan to ensure appropriate standard of care was provided. Staff 3 reported at the time of the event he/she left the resident in the bathroom and went to the nurses station. At the time of the event staff responded to sounds from the resident's room, found the resident on the floor and noted head injury. The resident was sent to the hospital and diagnosed with an acute subdural hematoma. Portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +OR0000806700,385120,NF,1/24/2013,Resident 1 was re-admitted 11/20/2012 with multiple diagnoses. The 1/8/2013 social service note indicated therapy review and need for day time care giver to be used by resident's family. Resident's discharge assessment and discharge instructions failed to include nursing services or the name and contact information for the home health agency. The physician orders for discharge did not include home health nursing services and incorrectly identified the therapy services. Revised orders signed on 1/18/2013 still did not contain nursing services request. The facility failed to ensure home health and private care giver services were in place prior to resident's discharge. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000811200,385120,NF,2/12/2013,"Resident 1 was admitted January 29, 2013 with multiple diagnoses. Resident care transfer information from the hospital identified the resident had dysphagia and required a pureed diet. On 2/7/2013 the resident received a regular textured diet, choked, was given the Heimlich Maneuver and was sent to the hospital. The resident required an upper endoscopy for removal of a foreign body. The facility procedure failed and the resident was given the wrong diet resulting in the resident choking. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +ES132301,385120,NF,1/31/2013,RV received both antibiotics and constipation medication on 1/23/2013 without documented negative effect. There were times the constipation medication was circled without notes on the back of the MAR as to why RV did not receive medication. Poor documentation could place RV at risk for harm. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000830100,385120,NF,5/16/2013,"Resident 1 was admitted 4/10/2013 with multiple diagnoses. Resident care plan indicated fall risk, two staff for ADLs, hip precautions, dialysis needs and diabetic monitoring. The hospital transfer sheet did not include use of TED hose or physician orders to use TED hose. W2 observed TED hose on the resident from admission until 4/21/2013. Multiple staff indicate the hose were in place during the day and removed at night. The facility failed to ensure there were orders to use the TED hose and care plan instruction for their use. The facility failed to provide all nursing care and services. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000880500,385120,NF,3/3/2014,"Resident 3 was admitted 1/31/2014 with diagnoses including diabetes. Staff 10 misread a insulin dose and after speaking with the resident gave the wrong dose. The facility failed to ensure staff understood clarification of medication and giving proper insulin dose. Staff 10 recognized the medication error, notified the physician and the resident was sent to hospital with a CBG of 402. Staff 11 failed to document a change of condition, hospitalization and or give appropriate treatment to Resident 7 and Resident 16 respectively. Multiple licensed nurses acknowledged the physician orders were confusing and clarification should have been done. The facility failed to have adequate systems in place to prevent Staff from administering one resident's medication to another resident. The facility failed to ensure 6 of 10 licensed staff followed professional standards of practice related to facility policy for signing that insulin does were correct; in particular Staff 28. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000880501,385120,NF,3/3/2014,"Resident 3 was admitted 1/31/2014 with diagnoses including diabetes. Staff 10 misread a insulin dose and after speaking with the resident gave the wrong dose. The facility failed to ensure staff understood clarification of medication and giving proper insulin dose. Staff 10 recognized the medication error, notified the physician and the resident was sent to hospital with a CBG of 402. Staff 11 failed to document a change of condition, hospitalization and or give appropriate treatment to Resident 7 and Resident 16 respectively. Resident 7's CBG was 30 and the resident required hospitalization. Resident 16 did not receive treatments as ordered and experienced discomfort and was at risk for respiratory occlusion. Multiple licensed nurses acknowledged the physician orders were confusing and clarification should have been done. The facility failed to have adequate systems in place to prevent Staff from administering one resident's medication to another resident. The facility failed to ensure 6 of 10 licensed staff followed professional standards of practice related to facility policy for signing that insulin does were correct; in particular Staff 28. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000876100,385120,NF,2/5/2014,"Resident 3 was admitted 1/31/2014 with diagnoses including diabetes. Resident was admitted with specific insulin orders, On 2/1/2014 resident received the wrong dose of insulin. Staff 10 was in a hurry, questioned the insulin dosage amount as he/she read the order twice, spoke with the resident and continued to administer the medication after speaking with resident. Staff 5 was in the room at the time the resident spoke with Staff 10 regarding the amount of insulin. Staff 10 used poor standard of care by not checking the amount of insulin with another licensed staff when he/she first questioned the dosage. The resident blood glucose was over 400 when he/she was transferred to the hospital for evaluation/treatment. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations were violated.",3,,Not Substantiated,Substantiated, +OR0000900200,385120,NF,6/2/2014,"Resident 27 was admitted 5/22/2014 with diagnoses including end stage renal disease. The complainant indicated resident wore pajamas all day and remained in same pajamas two days in a row. Resident's care plan indicated bathing on Tuesday and Fridays. Documentation reviewed and witness report indicated the resident received bathing, but it was not always documented. On 5/27/2014 there was no documentation the resident was offered a shower. The facility failed to provide al necessary care and services related to grooming and personal care. The facility was previously cited and was in a period of correction at the time of this event. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000900203,385120,NF,6/2/2014,Resident 27 was admitted 5/22/2014 with diagnoses including end stage renal disease. The complainant reported facility failure to administer all of the resident's medication. The resident did not receive Pro Source on 5/23/2014. The facility was in their correction period at the time of this event Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +ES146082,385120,NF,2/1/2014,"Witnesses reported exchange and yelling between RV1 and RV2. RV1 was unable to give relevant information. RV2 was able to give relevant information and ""showed remorse"" for his/her behavior. Staff were not following RV2's 5/22/2014 care plan for behavior. Staff did not set boundaries as RV2's care plan indicated resulting in interaction with RV1. RV1 was not injured, but was at risk for harm. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ES147465,385120,NF,6/13/2014,"On 6/14/2014 RV reported to W4 a complaint of pain when urinating and thought someone must have assaulted him/her in the night. W4 failed to immediately report the allegation although W4 understood he/she is a mandatory reporter. RV tested positive for an infection and did not think anyone molested him/her. RP2 and RP3 deny any inappropriate care. Both RP2 and 3 reported RV's unusual ramblings. RV's hospital test indicated an infection, but no one that was sexually transmitted. RV had no sign of trauma. Staff did fail to immediately report suspected abuse.",2,,Not Substantiated,Substantiated, +ES149090,385120,NF,10/29/2014,RV requires use of a paddle call light and reported need of the light being clipped to the draw sheet. RV reported loss of the call light number of times. RV reported having to yell for help. RV was at risk for harm when the call light was not within reach. RV's care plan was changed for further safety. Staff received further in-service. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ES146521,385120,NF,3/26/2014,"Evidence is inconclusive RP2 treated RV roughly. RV denied rough treatment and there were no marks or bruises attributed to RP2's transfer of RV. Staff reported RP2 is easily stressed/frustrated and can be rude at times per RV and other residents. The facility did counsel RP2 a previous time regarding stress and rudeness. Although RP2 was following RV's care plan for a one to two person transfer, RP2 repeatedly told RV to stand, but RV was unable to stand per W1. RV became distressed and crying. After conducting an informal conference and reviewing further evidence, it was found that RP2 failed to treat RV with all due respect. RP2 did make comments to a colleague in front of RV regarding RV's toileting occurring at meal times, but only in reference to RV having his/her meals disrupted by toileting; no reference to RV requesting to be toileted specifically at meal times. RV's care plan should address toileting prior to meal times to avoid disruption of RV's meal. Oregon administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Neglect +ES149137,385120,NF,11/3/2014,RV reported not receiving his/her pain medication timely after requesting the medication and was in significant pain for over an hour per time estimates RV provided. W1 found RV crying/moaning in pain and reported RV did not receive pain medication until 2:45 P.M. Witnesses (staff) report day shift ends at 2:00 P.M.; a note requesting the pain medication was written by day shift and was lost; RV did receive pain medication after other staff requested pain medication to be given; and the original note was eventually found. Witnesses report staff do leave sticky notes at times requesting pain medication; the facility will review this process. The facility failed to promptly medicate RV resulted in RV's continued pain which constitutes abuse. Oregon Administrative Rule violations occurred.,2,300,Substantiated,Substantiated,Neglect +ES147451,385120,NF,6/14/2014,Due to facility staff miscommunication RV was neither checked and or provided incontinence care as care planned. At approximately 6:00 A.M. RV was found soaked with urine from mid back to mid leg. Staff had spoken with RV at approximately 10:30 P.M.; and RV was dry and acting normal. At 4:30 A.M. RP2 noted RV saying strange things and alerted W5. RV's care was turned over to W4 who thought RV had been checked and changed. The facility failed to ensure RV's brief was changed timely resulting in a large quantity of incontinence soaking RV and RV's linens. A reasonable person would have been uncomfortable and or sustained a significant loss of dignity. The facility failure constitutes minor with potential for moderate harm and abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +ES150283,385120,NF,2/13/2015,"RV reported RP2 was assisting RV from the edge of bed when RV's knee ""went wobbly"" and RV and RP2 landed on the bed. RV reported RP2 and W1 returned a few minutes later with W1 telling RV that RV couldn't keep flopping over because RV was going to hurt someone. RV reported RP2 was ""clearly mad ' at RV. RV reported during transfer RV was told by RP2 to hold the bathroom bar and RP2 pushed RV's hand resulting in RV striking his/her face on the wall, W1 denied hearing RV or RP2 say anything and denied hearing any noise. RP2 reported assisting RV and RP2's hand must have been on the care belt. RV's care plan addressed short term memory problems with variable cognitive concerns with intervention of promoting dignity through conversations with the resident. RP2 reported barely speaking to RV and reported to W7 regarding confrontation. RP2 failed to follow RV's care plan regarding holding a conversation with RV. Witnesses deny ever observing RP2 being rough with resident's . The facility took appropriate and prompt intervention to ensure RV's safety.",2,,Not Substantiated,Substantiated, +ES150549,385120,NF,3/10/2015,"RV2 reported RP2 ""yelled"" at RV, RP2 said ""are you telling me my staff are liars"". RV2 reported shaking and not being able to ""function"". W1 reported RP2 was loud an reprimanded RV for "" picking at RV's appliance and told RV that the insurance would not pay daily for the appliance. W1 reported RP2 did ask RV if RV was calling staff ""liars"". W2 reported RP2's voice was raised. RP2 reported need to raise voice due to noise from the Jacuzzi as RP2 asked RV a question to confirm"" are you calling the staff Liars"". RP2 failed to treat RV with all due respect. The facility provided intervention to support RV feeling safe/secure while attempting to meet RV's preference in RV's treatment. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ES151312,385120,NF,5/13/2015,"RV was found soaked with urine including bedding and blankets. RV did not sustain skin changes, but was at risk. The facility knew of RP2's poor care the facility had moved RP2 around in the facility due to prior complaints per W4. RP2 denied poor care and reported checking residents at midnight, two A.M. and 4 A.M. RP3 reported being busy and was unable to get to RV until 10:00 A..M. Given the time of care RV may have been left without checking for incontinence from 4:00 A.M. until 10:00 A.M. for period of approximately 6 hours. Evidence is inconclusive if RP2 failed to provide care resulting in RV's being soaked. RP3 was to busy and the facility had inadequate staffing to provide care to RV. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES151539,385120,NF,5/15/2015,"RP2 failed to listen to RV's statement that RV did not take the medication RP2 was giving RV. RP2 failed to check the MAR against the physician orders and insisted RV take the medication. RP2 discovered the error; notified RV and RV's family; failed to notify RV's physician; and failed do notify the facility DNS. RP2 also failed to document the occurrence in RV's medical record. RV reported knowing the medication would not harm RV there were no known negative effects to RV. RP2 received counseling, probation and further medication management training. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000966800,385120,NF,5/4/2015,"Resident 1 was admitted in 2012 with multiple diagnoses. Resident's 2/13/2015 in room care plan identified resident required two person assist with be mobility. On 4/30/2015 at 5;30 A.M. the resident fell out of bed during care and sustained a 2x1 cm laceration to the head and injury to the left arm. The resident received treatment; and the physician and family were notified. Staff 9 had failed to follow the resident's care plan at the time of the event. Staff 7 and 8 both stated changing the resident and or providing one person bed mobility. Staff 9 reported working with the resident for approximately one month prior to the event and had not checked the resident care plan, but followed what care other staff provided. The facility failed to ensure all staff read and or follow the resident's care plan resulted in resident injury constituting abuse. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES151785,385120,NF,6/30/2015,"RP2 failed to treat RV with all due respect in telling RV that to an extent RV was responsible for RV's level of disability by not working to better him/herself. RP2 acknowledges crossing the line with the things RP2 says. RP2 reported in the past other residents have thanked RP2 for motivating them, but the fact remains RV was upset by RP2's comments. RV reported his/her feelings were hurt. W1 (facility staff) failed to promptly report the event which would place other residents at risk. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES152414,385120,NF,8/6/2015,"RV and W4 reported RV's cell phone and charger went missing. W4 reported a lot of people come and go in RV's room. RV reported the only visitor is W4. RV had no information regarding RV's social security card, but W4reported it missing. Staff deny any knowledge of RV's social security card. Staff searched for the phone and charger without success in finding either item. The facility will purchase a replacement phone and charger, as well as, perform daily checks monitoring RV's visitors. Facility failure to provide a safe environment resulting in loss of RV's possessions constitutes abuse. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +ES153110,385120,NF,10/8/2015,"Staff failed to follow RV's care plan dated 6/9/15; intervene as needed to protect the rights and safety of others, remove from situation and take to another location as needed. RV1 pulled RV2's hair when unable to get past RV2 as RV2's wheel chair lost power and blocked the door way. RV2 was not injured and the care plan was updated. The facility failure to monitor and ensure RV1 was redirected resulting in RV2's hair being pulled; and causing minor temporary pain constitutes abuse by neglect. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES153989,385120,NF,12/18/2015,"On 12-16-2015 at 2:30 P.M. staff observed RV1 and RV2's pain patches in place. Staff checked RV1 and RV2's pain patches at 10:30 P.M. and the patches were missing. Staff investigated and could not locate the patches. All staff with access to the RVs agreed to a urine test except RP2. All staff tested were negative for the missing pain patch medication. RP2 was suspended, left the building and employment was terminated. Staff assessed RV1 and RV2 and found no indication of increased pain due to the missing patches. Neither RV was able to provide relevant information regarding the missing pain patches. On 1/7/2016 RP2 admitted lying to the facility and the report investigator about having an outside independent lab do a urine and or blood test. RP2 denied taking the pain patches. Preponderance of evidence substantiates RP2 took RV1 and RV2's pain patches for RP2's personal gain which constitutes abuse. The facility continues to monitor resident pain patches. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Financial abuse +ES164165,385120,NF,12/30/2015,"RV1 and RV2'ds pain patches went missing and staff replaced the patches. W1 reported patches are taped in place, every shift checks patch placement and staff on shift tested negative. W1 reported increased checks are being completed. Neither resident is able to give relevant information. Documentation review indicates RV1's pain patch went missing at 2:00 P.M. on 12/28/2015 and at 6:00 A.M. on 12/29/2015. RV2's patch went missing on 12/30/2015. the facility notified police and APS; replaced the pain patches. The facility failed to ensure a safe environment for cognitively impaired RV1 and RV2's pain patches. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Financial abuse +OR0000662600,385121,NF,1/21/2011,"Resident 1 was admitted with multiple diagnoses including UTI with sepsis and cognitive impairment. Resident 1's care plan of 1/8 & /17/11 indicated Resident 1's fall risk with varied interventions including a bed sensor. On 1/19/11 staff found Resident 1 next to his/her bed; alarm not on. Staff 2 had turned off the alarm at 4:00 A.M., toileted Resident 1 and observed Resident 1 sleeping at 6:30 A.M. Staff 2 stated he/she probably forgot to turn the alarm back on. Staff did not observe notable injury until later in the day. An x-ray found a fractured wrist. Staff 2 received counseling to check alarms. Resident 1 could have turned off the bed alarm, but had not done so in the past. Alarms in and of themselves will not prevent all falls. Resident 1 stated on 2/8/11 that now two alarms are used. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +BC117351B,385121,NF,6/27/2011,Staff left RV in view with out a sheet covering RV. RV did have a brief and gown on. RP3 apologized to RV's family. RP3 was counseled to be more careful and pull up bed covers.,2,0,Not Substantiated,Substantiated, +BC117630,385121,NF,8/3/2011,"RV was unable to give relevant information. Witnesses gave conflicting evidence regarding when RV received his/her 8-11 P.M. medication. RP2 reported looking in RV's room/bathroom at around 9:30, but RV was out of the room. Staff found out RV had been on a walk with a student nurse. RV received his/her medication around 11:30 P.M. per RP2. The facility has discussed medication sign outs with RV and RV's family for future times when RV may be out at a medication pass time. The facility discussed procedures with staff. At the time of the incident the facility failed to provide an adequate medication administration system.",2,0,Not Substantiated,Substantiated, +OR0000790300,385121,NF,10/19/2012,"Resident 1 was admitted 10/14/2012 with diagnoses including a pelvic fracture and dementia. The 10/14/2012 care plan revealed a two person transfer using pivot transfers. On 10/18/2012 Staff 2 (RP2) failed to follow the care plan and transferred the resident by his/herself, heard a cracking sound and later x-rays confirmed a left arm fracture. Staff 2 confirmed failing to read resident's care plan and reported Staff 4 reported using a one to two person transfer although Staff denies this. Poor communication and failure to follow Resident 1's care plan resulted in injury to Resident 1. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure represents an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +BC134622,385121,NF,10/3/2013,"RV was to receive a specific diet. Staff requested additional food for RV without staff verifying RV's received diet as ordered. While RV sustained a change in condition, RV's physician reported RV's change of condition was due to over eating; not due to RV receiving diet other than ordered. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC145767A,385121,NF,12/25/2013,"The facility failed to have an adequate system to provide safe use of a warm pack. Staff had been using a pack designed for use with ice; not designed for use with hot water. Staff heated water in the ice pack bag, asked RV if it was ok, placed the pack and minutes later heard RV yelling. Staff found RV with a wet bed and red skin. RV developed blisters requiring treatment. The facility failure to ensure a safe system for applying warm packs resulted in resident injury and constitutes abuse. Oregon Administrative Rule violations occurred.",3,350,Substantiated,Substantiated,Neglect +BC145767B,385121,NF,12/25/2013,RV received extra calcium citrate one time. RV did not sustain any harm. The potential for harm was minimal. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +BC151011,385121,NF,2/24/2015,"Multiple concerns were voiced regarding RV's care as indicated in the following reported issues. RV developed an infection and was transferred to a private room. RV missed a care planned shower on 2/22/2015. Witnesses reported one evening RV was not served dinner and a alternate meal of a sandwich was delivered. RV's swollen red finger was treated per physician orders. W1 reported RV stated staff left RV on the commode, but evidence is inconclusive if RV hade decided not to use the call light for assistance. The facility failed to provide all care planned care in a timely and or consistent manner. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0001025600,385121,NF,11/4/2015,"Resident 1 was admitted 9/16/2015 with diagnoses including brain cancer. A 9/15/2015 nursing note indicated the resident with a ""pea sized open area to the coccyx/sacrum. The facility failed to assess and provide a care plan for a resident at risk for avoided skin breakdown. Between 9/18 and 9/21/2015 there was no description or assessment of the resident's wound. A 9/22/2015 nursing note indicated a Stage II pressure ulcer; care plan was up dated 9/28/2015. relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000729400,385125,NF,11/21/2011,Evidence and interviews indicated facility failed to assess and care plan potential accident hazards for the use of a shower chair and failed to provide Resident #1 adequate fall supervision. Resident #1 fell and sustained fractures and lacerations. Federal penalty recommended relevant portions of the complaint report survey are attached.,3,0,Substantiated,Substantiated,Neglect +BH120723,385125,NF,7/27/2012,Evidence and interviews indicated facility failure to ensure Resident #1 did not receive anti coagulation medication that Resident #1's physician ordered be held on 07/26/2012. Resident #1 was erroneously administered the anti coagulation medication from 07/27 through 07/30/2012.,2,0,Not Substantiated,Substantiated, +BH121905,385125,NF,12/16/2012,Evidence and interviews indicated facility failure to protect Resident #1 from financial exploitation. Resident #1 had $225 taken from her/his wallet on 12/15/2012. Facility's failure to ensure a safe environment for Resident #1's money is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BH134204,385125,NF,8/18/2013,"Evidence and interviews indicated RP2 (CMA)charted facility residents as needed (PRN) narcotic medication as given when RP2 was giving a resident one tablet and keeping the second tablet for her/himself In addition, if a resident asked for one tablet, RP2 charted that she/he gave two and kept one for her/himself. RP2's illegal and improper use of resident_x001A_s narcotic medications is a violation of resident rights, considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BH146079,385125,NF,1/19/2014,"Based on evidence and interviews it was determined the facility failed to provide a safe medication administration system resulting in Resident #1 sustaining continued pain. The facility failure to provide a safe medication administration system and failure to ensure appropriate pain control for Resident #1 resulting in Resident #1 severe leg pain are violations of resident rights, are considered neglect of care and constitutes abuse.",3,400,Substantiated,Not Substantiated,Neglect +BH146244,385125,NF,3/1/2014,"Evidence and interviews indicated facility failed to ensure Resident #1 received timely assistance with incontinence care on 03/01/2014. Resident #1 did not receive assistance with incontinence care for at least two and a half hours after asking staff for help. The facility failure to provide Resident #1 timely care with toileting is a violation of resident rights, considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000925300,385125,NF,10/7/2014,"Evidence and interviews indicated facility failure to act timely to Resident #1's change in medical condition resulting in hospitalization and kidney failure. Facility failure to provide Resident #1 adequate care and services with a change in Resident #1_x001A_s medical condition, resulting in Resident #1 requiring hospital treatment, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000932600,385125,NF,11/12/2014,"Evidence and interviews indicated facility failure to implement their abuse prevention policy for reporting neglect of care for Resident #2 placing Resident #2 at risk for continued neglect. Evidence and interviews indicate facility failure to ensure staff followed care planned interventions for safety for Resident #2. Facility failure to ensure staff followed care planned interventions for safety, resulting in Resident #2 sustaining a large left hand skin tear, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +OR0000941700,385125,NF,12/23/2014,Evidence and interviews indicated facility failure to obtain treatment orders for Resident #3. This failure placed Resident #3 at risk for worsening pressure ulcers. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +BH150421,385125,NF,11/27/2014,"Evidence and interviews indicated facility failure to maintain an adequate medication administration system for Resident #1. Facility documentation indicated medication administration errors for Resident #1 on 7/9/14, 10/13/14, and 11/27/14. The facility failure to provide a safe medication administration system resulting in Resident #1 requiring hospital evaluation after sustaining 13 medications on 11/27/14 that were not prescribed to Resident #1, are violations of resident rights, are considered neglect of care and constitutes abuse.",3,450,Substantiated,Substantiated,Neglect +OR0000954000,385125,NF,3/11/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services to ensure Resident #1's care plan was followed for bed mobility with incontinence care. Witness #1 (former CNA) was assisting Resident #1 with incontinence care in bed 3/10/2015. Resident #1 rolled to the edge of the bed, fell hitting her/his left elbow, and left side of her/his head. Witness #1 said she/he failed to check Resident #1's care plan indicating Resident #1 was totally dependent on staff and she/he required two-person assistance for repositioning in bed and she/he was unable to say what caused Resident #1 to roll out of bed. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated,Neglect +OR0000975300,385125,NF,6/11/2015,"Evidence and interviews indicated facility failure to develop care planned interventions to address Resident #1's fall risks, and implement a care planned intervention to maintain safety for Resident #1 and Resident #2 who had falls. Resident #1 was admitted on 1/7/2015 and sustained non-injury falls on 1/10 and 1/12/2015. On 1/13/2015, a fall care plan was developed for Resident #1 and interventions were identified to prevent falls. Resident #1 had no additional falls between 1/14 and 1/28 when she/he was discharged from the facility. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000986900,385125,NF,8/4/2015,"Evidence and interviews indicated the facility failed to develop care-planned interventions to address fall risk and failed to implement a care-planned intervention to maintain safety for Resident #1 and Resident #2. In addition, Staff #2 assisted Resident #2 without using a gait belt with transferring on or about 3/14/2015 and Resident #2 sustained a skin tear to her/his left forearm. The facility failure to provide Resident #2 adequate care and safety services with a transfer, resulting in Resident #2 sustaining a skin tear, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +BH150634,385125,NF,1/13/2015,"Resident #1_x001A_s care plan dated 1/11/2015 indicated Resident #1 should be monitored for high aspiration risk and have pureed texture, honey-thick texture for meals. Witness #2 said she/he was visiting Resident #1 when two different staff members offered Resident #1 liquids to drink which were not _x001A_honey-thick_x001A_ fluids. In addition, on or about 1/18/2015, witness #2 intervened when RP2 (licensed nurse) attempted to give Resident #1 water and whole pills. RP2 said she/he did not notice the sign indicating Resident #1 was an aspiration risk, and she/he was not familiar with Resident #1_x001A_s care needs. In addition, RP2 told witness #2 it was up to her/his _x001A_discretion_x001A_ to provide Resident #1_x001A_s medication the inadequate way she/he attempted to administer Resident #1_x001A_s medication prior to witness #2_x001A_s intervention.",3,250,Not Substantiated,Substantiated, +MS092790,385126,NF,11/30/2009,"On November 30, 2009 W#8 was terminated from providing Facility residents with manicure and pedicure services. On December 3, 2009 W#1 said several weeks_x001A_ earlier concerns were voiced regarding the manicure, pedicure services W#8 provided residents. Facility staff said residents_x001A_ nails did not look adequately done. W#2 said the quality of W#8_x001A_s services had declined. W#8 said she had not done Resident #2_x001A_s nails as agreed upon, but it was an _x001A_honest mistake_x001A_ resulting from an overly full schedule. W#8 said Resident #3 had pre-paid W#8 and W#8 owed Resident #3 $50. W#8 refunded Resident #3_x001A_s pre-paid money for services not provided.",2,0,Not Substantiated,Substantiated, +MS105312,385126,NF,9/20/2010,"On September 20, 2010 RP2 (licensed nurse) entered Resident #1_x001A_s room and told Resident #1 she/he was going to administer Resident #1 a suppository because Resident #1 had not had a bowel movement for three days. Facility documentation dated September 20, 2010 indicated Resident #1 said _x001A__x001A_RP2 and RP3 (CNA) held [Resident #1] against [Resident #1_x001A_s] will and gave [Resident #1] a suppository_x001A__x001A_ RP2 indicated Resident #1 was _x001A_fighting care_x001A_ and did not want the suppository however RP3 rolled Resident #1 over and RP2 administered Resident #1 the suppository. RP3 indicated Resident #1 was _x001A_more upset than_x001A_ RP3 had ever seen, Resident #1 was swinging her/his pillow and yelling while the suppository was administered.",3,450,Substantiated,Substantiated,Neglect +MS105644,385126,NF,11/8/2010,"Facility failed to provide a secure environment resulting in Resident #1, Resident #2 and Resident #3 having money stolen from them in their rooms while residing at the facility between 9/17/2010 through 11/8/2010. Refer to attached complaint report for information.",2,0,Not Substantiated,Substantiated,Financial abuse +MS116657B,385126,NF,4/1/2011,"Evidence and interviews indicated facility failed to ensure staff provided timely assistance in response to Resident #1's call light requests. Resident #1 was care-planned as continent; however Resident #1 started wearing incontinence briefs so there was ""less of a problem"" when staff continued to fail to timely answer call light requests for toileting assistance. Resident #1 was frustrated and anxious about using a call light to request care assistance.",3,0,Substantiated,Substantiated,Neglect +MS117145,385126,NF,6/1/2011,"On June 1, 2011 Resident#1 left her/his wallet the bed while using the bathroom. When Resident #1 came out of the bathroom, she/he realized that her/his wallet was on the bed. Resident #1 said $32 had been taken from her/his wallet. Resident #1 did not see who took the money from her/his wallet and there were no witnesses regarding who took $32 from Resident #1's wallet on June 1, 2011.",2,0,Not Substantiated,Substantiated,Financial abuse +MS117799B,385126,NF,8/24/2011,"Evidence and interviews indicated Resident #1 was admitted to the facility with two sutures on her/his left big toe. Facility staff failed to assess Resident #1 had sutures on her/his left big toe. Care plan instructions indicated Resident #1 was to receive weekly bathing assistance, skin assessments and nail care. The two sutures on Resident #'1 big toe remained unnoticed by facility staff for approximately four months before they were removed.",2,0,Not Substantiated,Substantiated, +MS117799C,385126,NF,8/24/2011,Evidence and interviews indicated Resident #1 had a couple of instances of needing to wait about 30 minutes for staff toileting assistance. Evidence and interviews indicated Resident #3 had waited at much as 30 minutes to an hour for staff toileting assistance.,2,0,Not Substantiated,Substantiated, +OR0000716901,385126,NF,9/21/2011,EEvidence and interviews indicated facility failed to provide ongoing assessment and treatment of Resident #1. Resident #1 experienced the recurrence of an unstageable (deep tissue) wound and additional Stage II-III wounds that were untreated. Federal penalty recommended; relevant portions of the complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +MS118255,385126,NF,10/11/2011,"Evidence and interviews indicated RP2 (CNA) assisted RV a number of times to transfer to and from bed/wheel; chair/toilet. RV's care plan of record notes a one person transfer. RP2 stated the pocket care plan directed care staff to use a slide board and another person, but RP2 reported RV insisted RP2 assist RV by themselves. RP2 readily admitted using poor judgment by not seeking further direction from the charge nurse. RP2 reported attempting to find the charge nurse one time, but got busy. RV reported pain when RP2 touched RV's unwrapped arm. RP2 reported RV's care plan did not indicate the arm was fractured nor did RV tell RP2 that the arm was fractured. During subsequent transfers RV placed his/her arms to their side and RP2 used the gait belt to guide RV. RP2 asked RV a number of times if RV was in pain and RV said no. RV later requested pain medication after being up for an extended time. The facility failed to ensure RV's care plan gave adequate instruction for transfers to prevent unnecessary discomfort. The facility failure constitutes neglect of care (abuse).",2,0,Substantiated,Substantiated,Neglect +MS118253,385126,NF,10/17/2011,Evidence and interviews indicated facility failed to protect Resident #1 from sustaining the theft of her/his gold rings.,2,300,Substantiated,Substantiated,Financial abuse +MS118406,385126,NF,10/31/2011,"Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services on October 31, 2011 after Resident #1 sustained a wheelchair accident.",2,300,Substantiated,Substantiated,Neglect +MF129053,385126,NF,1/25/2012,Evidence and interviews indicated facility failed to provide Resident #1 timely pain medications.,3,400,Substantiated,Substantiated,Neglect +MS129162B,385126,NF,2/5/2012,Resident #1 had difficulty swallowing and was supposed to be sitting upright to eat or drink as a choking precaution. Evidence and interviews indicated facility staff failed to follow Resident #1's care plan and consistently ensure Resident #1 was sitting upright during mealtime and when provided medication.,2,0,Not Substantiated,Substantiated, +MS117824,385126,NF,8/18/2011,Evidence and interviews indicated RP2 (CNA) removed Resident #1's clothing against Resident #1's wishes on 08/18/2011. Resident #1 was upset and cried when RP2 took away Resident #1's shirt. (This complaint investigation report was initially written under complaint investigation #MS117842.),2,0,Not Substantiated,Substantiated, +MF129796,385126,NF,4/16/2012,"Evidence and interviews indicated facility failure to administer Resident #1_x001A_s narcotic pain medication on 04/16/2012. Resident #1 said she/he had through ""horrible withdrawals"" in part because of the failure to timely administer the pain medication.",2,0,Substantiated,Substantiated,Neglect +MS129950,385126,NF,4/30/2012,Evidence and interviews indicated facility failure to provide Resident #1 appropriate care on 04/30/2012 resulting in Resident #1 sustaining unreasonable discomfort.,2,300,Substantiated,Substantiated,Neglect +MF120617,385126,NF,6/3/2012,"Evidence and interviews indicated RP2 (CMA) borrowed narcotic medication from Resident #1 and administered the narcotic medication to Resident #2 on 06/03/2012 and 06/04/2012. In addition, there were seven narcotic medications missing or unaccounted for.",2,400,Not Substantiated,Substantiated, +MS120680,385126,NF,5/25/2012,"On May 25, 2012 facility staff RP2 (CNA) and W1 (CNA) assisted Resident #1 with transferring from her/his bed to a wheeled assistive device using a Hoyer lift. During the transfer, the Hoyer lift tipped and part of the Hoyer fell over onto Resident #1. Resident #1 sustained an abrasion to the side of her/his scalp and an additional superficial abrasion mid-scalp.",2,300,Substantiated,Substantiated,Neglect +MS120894,385126,NF,8/24/2012,Evidence and interviews indicated facility failure to provide adequate medication administration care and services resulting in Resident #1 sustaining confusion and psychosis.,3,500,Substantiated,Substantiated,Neglect +MS120910,385126,NF,8/21/2012,The Facility_x001A_s failure to provide adequate medication administration for Resident #1 resulted in Resident #1 sustaining elevated bleeding time.,2,300,Substantiated,Substantiated,Neglect +MS120689,385126,NF,3/2/2012,Evidence and interviews indicated facility failure to timely investigate and report Resident #1's injury of unknown cause.,1,0,Not Substantiated,Substantiated, +OR0000785300,385126,NF,9/24/2012,Evidence and interviews indicated facility failure to adequately administer Resident #1's narcotic pain medication. Relevant portions of the survey complaint report are attached.,2,200,Not Substantiated,Substantiated, +OR0000785301,385126,NF,9/24/2012,Evidence and interviews indicated facility failed to ensure Resident #1 and Resident #2's PICC line treatments were completed according to physician orders. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +OR0000788100,385126,NF,10/8/2012,Evidence and interviews indicated facility failure to provide the necessary care and services to prevent Resident #1's 10/03/2012 fall; Resident #1 sustained a right hip fracture as a result of the fall. Federal penalty recommended; relevant portions of the complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000806000,385126,NF,1/22/2013,Evidence and interviews indicated facility failure to ensure physicians and family received timely notification regarding changes in Resident #86's change in condition. This failure placed the resident at risk for delayed treatment and unaddressed changes in condition. Evidence and interviews indicated facility failure to obtain timely treatment for Resident #86's change in condition and failed to report a potential injury to the resident's knee. Resident #86 was found to have a painful displaced femur fracture which had initial symptoms identified on 12/25/2012 night shift and was not treated until the evening of 12/27/2012. Evidence and interviews indicated facility failure to provide Resident #86 adequate supervision to prevent an accident. Resident #86 sustained a painful fracture after the resident's leg/foot was caught during a transfer. Relevant portions of the complaint report investigation are attached; federal penalty recommended.,3,0,Substantiated,Substantiated,Neglect +OR0000803601,385126,NF,1/14/2013,"Evidence and interviews indicated facility failure to insure physicians and family received timely notification regarding changes in Resident #95 and Resident #196_x001A_s changes in conditions. This failure placed the residents at risk for delayed treatment and unaddressed changes in condition. Relevant portions of the complaint report investigation are attached. Relevant portions of the complaint report investigation are attached, federal remedies recommended.",2,0,Substantiated,Substantiated,Neglect +OR0000803602,385126,NF,1/14/2013,Evidence and interviews indicated facility failed to provide adequate pain medication administration for Resident #315 and Resident #320. This resulted in untreated pain for Resident #315 and Resident #320. Federal penalty recommended; relevant portions of the complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000803603,385126,NF,1/14/2013,"Evidence and interviews indicated facility failure to consistently provide Resident #319 with a privacy cover for a drainage collection bag, placing Resident #319 at risk for diminished dignity.",2,0,Not Substantiated,Substantiated, +MS134055,385126,NF,8/7/2013,Evidence and interviews indicated facility failure to ensure Resident #1 was protected from RP2's inappropriate verbalizations directed at Resident #1 in a public area of the facility in front of other people.,2,,Not Substantiated,Substantiated, +MS135536,385126,NF,12/31/2013,Evidence and interviews indicated RP2 (CNA) took two of Resident #1's bank account checks. Facility failure to ensure Resident #1's checks were taken by RP2 without Resident #1's knowledge or consent is considered financial exploitation.,2,,Not Substantiated,Substantiated,Financial abuse +OR0000889800,385126,NF,4/10/2014,"Evidence and interviews indicated facility failure to complete a side rail safety assessment for Resident #1 who experienced a fall from bed sustaining an abrasion and requiring hospital evaluation. The Facility failure to provide Resident #1 adequate care and services related to a fall are violations of resident rights, are considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +MS147002,385126,NF,5/5/2014,"Evidence and interviews indicated RP2 (CNA) threatened Resident #1 on May 5, 2014 while providing care assistance. Witness #1 (facility staff) indicated, RP2 entered [Resident #1's] room. . . RP2 took the call light in her/his hand, lowered her/his face to [Resident #1's] face and told [Resident #1], ""I'll break your fingers if you keep hitting this call light."" The facility failure to protect Resident #1 from RP2's verbal and mental abuse are violations of resident rights, are considered neglect of care and constitute abuse. 12/5/2014- AMENDED LOD - Evidence and interviews indicated facility failure to assure Resident #1 received care assistance from RP2 that assured Resident #1 consideration, respect and dignity.",2,,Not Substantiated,Substantiated, +OR0000906201,385126,NF,7/2/2014,Evidence and interviews indicated facility failure to ensure timely notification of Resident #28's physician regarding Resident #28's change of medical condition. This failure put Resident #28 at risk for a potential delay in treatment. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +MS148440,385126,NF,9/3/2014,"Evidence and interviews indicated facility failure to protect Resident #1 from the theft of $181 that Resident #1 left with witness #5 (administrator) for safe keeping. Witness #5 said she/he hand delivered $181 to Resident #1's new residence, however facility staff at the new location denied ever receiving $181. In addition, Resident #1 was discharged from the facility without the walker she/he had at the time of moving into the facility. The facility failure to provide Resident #1 a safe environment resulting in the theft of money and loss of resident property are considered neglect of care and constitutes financial abuse.",2,,Substantiated,Substantiated,Financial abuse +MS147899,385126,NF,7/21/2014,"Evidence and interviews indicated facility failure to protect Resident #1 from financial exploitation resulting in the theft of Resident #1's personal identification including social security card, driver's license and bankcards. The facility reimbursed Resident #1 for $138 which was the dollar amount Resident #1 indicated she/he had when admitted to the facility. Resident #1 said there was an additional $300.00 she/he obtained after admission to the facility that was stolen. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining loss of money and personal property is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,400,Substantiated,Substantiated,Financial abuse +OR0000916900,385126,NF,8/22/2014,Evidence and interviews indicated facility failure to administer Resident #2_x001A_s medications as orders. The facility failure to administer Resident #2_x001A_s medication as ordered placed her/him at risk for complications in her/his health status. Evidence and interviews indicated facility failure to accurately transcribe Resident #2_x001A_s medication orders. The facility failure to accurately transcribe medication orders for Resident #2 placed her/him at risk for complications in her/his health status. Relevant portions of the complaint report investigation are attached.,2,400,Not Substantiated,Substantiated, +OR0000925900,385126,NF,10/10/2014,Evidence and interviews indicated facility failure to timely notify the physician and interested family members when Resident #4 had a significant change in medical condition. This failure placed Resident #4 at a risk for health complications. Relevant portions of the complaint report investigation are attached.,2,400,Not Substantiated,Substantiated, +OR0000925901,385126,NF,10/10/2014,Evidence and interviews indicated facility failure to provide the necessary care and services related to ensuring Resident #4 had adequate nourishment through her/his gastrostomy tube. This failure placed Resident #4 at risk for not receiving adequate nourishment. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000923000,385126,NF,9/22/2014,"Evidence and interviews indicated facility failure to follow standard of practice for obtaining timely wound care orders for Resident #1 who had a wound, placing Resident #1 at risk for wound complications. Facility documentation dated 9/11/2014 indicated Resident #1's left foot wound was painful and the wound would be viewed after the resident received pain medication. Physician orders dated 9/11/2014 did not include wound care for Resident #1's left foot wound. A physician's telephone order dated 9/14/2014 indicated the facility received Resident #1's left foot wound treatment orders. Staff #2 (licensed nurse) indicated it should not have taken three days before the facility obtained Resident #1's wound care orders. Relevant portions of the complaint report investigation are attached.",3,750,Substantiated,Substantiated, +MS149269,385126,NF,11/18/2014,"Evidence and interviews indicated facility failure to ensure adequate care and services related to Resident #1's catheter care. Witness #1 (licensed nurse) said staff should have emptied Resident #1's catheter bag at the end or shift or when it was full and at least once daily. Facility staff indicated Resident #1's catheter bag was not timely changed and the catheter bag became so full it was observed to be backed up in November 2014. Evidence indicated Resident #1 did not receive adequate catheter on at least five dates in November 2014. The facility failure to ensure Resident #1 received adequate catheter care resulting in Resident #1 sustaining pain and a urinary tract infection is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,1000,Substantiated,Substantiated,Neglect +MF149227,385126,NF,11/13/2014,Evidence and interviews indicated facility failure to ensure locked storage was offered and/or provided for Resident #1_x001A_s money. A family member gave Resident #1 $500.00 on or about 11/06/2014. Resident #1 said she/he left $250.00 in her/his pant pocket and laid the pants on a chair in her/his room. Resident #1 said she/he placed an additional $250.00 in her/his wallet in a bedside drawer. Resident #1 said she/he noticed the $250.00 had been stolen from her/his wallet on or about 11/07/2014.,3,200,Not Substantiated,Substantiated,Financial abuse +MS149424,385126,NF,11/30/2014,"Evidence and interviews indicated facility failure to ensure proper care planning for Resident #1 who had a history of diagnoses including bi-lateral shoulder dislocations. Nursing notes for Resident #1 indicated on 12/1/2014 Resident #1 had right arm and shoulder bruising measuring 20 cm by 90 cm extended to Resident #1_x001A_s elbow. Resident #1_x001A_s left shoulder showed bruising 14 cm by 8 cm distal and _x001A__x001A_closes to [Resident #1_x001A_s] shoulder dark purple/blue 4 cm by 4.5_x001A__x001A_ The facility failure to ensure adequate care planning and failed to ensure adequate transfer assistance for Resident #1 resulting in Resident #1 sustaining a dislocated shoulder, pain and bruising is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,500,Not Substantiated,Substantiated,Neglect +MF149426,385126,NF,11/26/2014,"Evidence and interviews indicated RP2 (CNA) solicited a loan of $175.00 from Resident #1. Resident #1 said she/he, ""felt badly"" for RP2 but she/he wanted to lend RP2 the money. RP2 failed to pay Resident #1 back the $175.00 on 11/25/2014 as initially promised. RP2 acknowledged she/he was prohibited from accepting a loan from Resident #1. Witness #1 (licensed nurse) said RP2 admitted borrowing the money to pay her/his electric bill. Witness #1 said on or about 12/3/2014 RP2 provided $175.00 to witness #1 to give to Resident #1 as payment for the loaned money.",2,,Not Substantiated,Substantiated, +MS159825A,385126,NF,1/7/2015,"Evidence and interviews indicated facility failure to administer medication as ordered for Resident #1_x001A_s as needed (PRN) pain medications. The facility failure to ensure the timely administration of Resident #1_x001A_s pain medication resulting in Resident #1 experiencing delayed pain relief and unreasonable discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,500,Substantiated,Substantiated,Neglect +MS159825B,385126,NF,1/7/2015,Evidence and interviews indicated facility failure to ensure an adequate medication administration system for Resident #1 when failing to administer Resident #1_x001A_s medications as ordered and failing to maintain accurate medication administration records for Resident #1_x001A_s medication administration.,3,,Not Substantiated,Substantiated, +OR0000931100,385126,NF,11/4/2014,Evidence and interviews indicated facility failure to prevent the use of physical restraints on Resident #1. Staff #18 (CNA) stated she/he was having a difficult time calming Resident #1 and she/he used compression socks to hold Resident #1's feet in a wheelchair so Resident #1 would not fall out of the wheelchair and be injured. The facility failure to prevent the use of physical restraints on Resident #1 placed Resident #1 at risk of injury from an improperly used restraint. Relevant portions of the complaint report investigation are attached.,3,250,Not Substantiated,Substantiated, +OR0000933400,385126,NF,11/13/2014,"Evidence and interviews indicated facility failure to provide Resident #2 adequate care and services related to pressure sore precautions. Facility failure to provide Resident #2 adequate pain pressure sore care and services resulting in Resident #2 developing a pressure sore on her/his heel is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +OR0000942800,385126,NF,12/31/2014,"Evidence and interviews indicated facility failure to follow Resident #7's care plan and use an appropriate shower device for Resident #7. A 12/15/2014 care plan for Resident #7 indicated two staff were to assist with showers and a mechanical lift should be used for all transfers. On 12/8/2014 staff #24 (CNA) indicated she/he and another CNA transferred Resident #7 into a shower chair using a mechanical lift. Staff #24 said she/he assisted Resident #7 back to her/his room by her/himself using a shower chair. When returning Resident #7 to her/his room, Staff #24 said she/he turned his back on Resident #7 and she/he ""must have lost her/his balance,"" Resident #7's face hit the bed frame. Staff #24 failed to timely report Resident #7's fall with bruising and reported the circumstances later on 12/8/2014. Facility failure to follow Resident #7_x001A_s care plan resulting in Resident #7 falling and sustaining injury is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,300,Substantiated,Substantiated,Neglect +OR0000942901,385126,NF,1/5/2015,"Evidence and interviews indicated facility failure to provide Resident #6 the adequate care and services related to monitoring an abdominal wound incision. Facility failure to provide adequate wound care treatment resulting in Resident #6 requiring hospital treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report are attached.",2,850,Substantiated,Substantiated,Neglect +OR0000942902,385126,NF,1/5/2015,"Evidence and interviews indicated facility failure to provide Resident #6 adequate care and services related to providing wound care for an abdominal wound incision. Facility failure to provide adequate wound care treatment resulting in Resident #6 requiring hospital treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report are attached.",2,,Substantiated,Substantiated,Neglect +OR0000943600,385126,NF,1/8/2015,Evidence and interviews indicated facility failure to complete a timely incident and investigation report related to a fall Resident #4 sustained on 12/14/2014. Evidence and interviews indicated facility failure to follow Resident #4's care plan and use an appropriate shower device for Resident #4 who sustained a fall on 12/14/2014. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +MS150336,385126,NF,2/23/2015,"Evidence and interviews indicated facility failure to follow Resident #1_x001A_s care plan for bowel care. Resident #1_x001A_s February 2015 care plan indicated she/he had a history of bowel issues requiring medical treatment. Facility documentation indicated Resident #1 did not have a bowel movement for 10 consecutive days, from 2/5/2015 through 2/14/2015. The facility failure to provide Resident #1 adequate bowel care treatment resulting in Resident #1 sustaining ten days of constipation and abdominal pain requiring hospital treatment is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,500,Substantiated,Substantiated,Neglect +MF150683B,385126,NF,3/23/2015,Evidence and interviews indicated facility failure to assure Resident #1 and Resident #2 rights' related to circumstances related to the care provided by RP2 (CNA) on or about 3/20/2015.,2,,Not Substantiated,Substantiated, +MS152967,385126,NF,9/30/2015,Evidence and interviews indicated facility failure to provide Resident #1 and Resident #2 a safe environment regarding their individual allegations of lost or stolen money. Evidence and interviews indicated facility failure to report suspected theft of monies. Evidence and interviews failed to indicate facility offered Resident #1 and Resident #2 adequate lockable storage options thereby failing to provide a safe environment to prevent the theft or loss of resident money.,2,,Not Substantiated,Substantiated, +OR0000998501,385126,NF,9/1/2015,Evidence and interviews indicated facility failure to provide Resident #3 and Resident #8 adequate medication and treatment as ordered by the physician. This failure placed Resident #3 and Resident #8 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,0,,Not Substantiated,Substantiated, +OR0001013700,385126,NF,10/8/2015,"Evidence and interviews indicated facility failure to adequately maintain Resident #1's clinical records, failing to ensure they were complete, accurate, and systemically organized. This failure placed Resident #1 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001013703,385126,NF,10/8/2015,"Evidence and interviews failed to indicate facility failure to provide Resident #1 adequate care and services related to ensuring resident safety. However, evidence and interviews indicated facility failure to ensure Resident #3 received adequate supervision and failed to provide and plan the appropriate number of staff to ensure a safe transfer was completed for Resident #3 this put Resident #3 at risk for accidents. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000663400,385132,NF,1/25/2011,The facility failed to provide timely assessment and monitoring when Resident #1_x001A_s surgical incisions became infected requiring hospital treatment and further surgical intervention. Relevant portions of the survey report are attached.,4,2500,Substantiated,Substantiated,Neglect +HB116328,385132,NF,2/11/2011,"Evidence and interviews indicated facility failed to administer two different physician ordered medications for Resident #1 on December 16, 2010. Resident #1 said she/he suffered stomach pain and nausea because she/he was not administered the prescribed medication.",2,0,Substantiated,Substantiated,Neglect +HB116403,385132,NF,2/22/2011,"Resident #1 said she/he was fearful of RP2 (certified nursing assistant) when RP2 handled Resident #1 roughly the morning of 2/22/2011. Facility investigation notes and staff interviews indicated RP2 became irritable, started knocking things around and talking under her/his breath in frustration and anger while providing care to Resident #1 on 2/22/2011.",2,0,Not Substantiated,Substantiated, +OR0000707700,385132,NF,8/15/2011,"Evidence and interviews indicated staff #12 (CNA) failed to provide Resident #2 adequate care and services related to a fall on 8/7/2011, resulting in Resident #2 sustaining a fracture and hospitalization. Federal penalty recommended relevant portions of the complaint report are attached.",3,0,Substantiated,Substantiated,Neglect +HB129596,385132,NF,3/24/2012,Evidence and interviews indicated facility failure to ensure Resident #1's rights when facility staff provided Resident #1 care assistance on 03/24/2012.,2,0,Not Substantiated,Substantiated, +HB120718,385132,NF,6/10/2012,Evidence and interviews indicated Resident #1 was not administered medication as ordered on 06/19/2012 and 06/30/2012.,2,0,Not Substantiated,Substantiated, +HB134587B,385132,NF,10/2/2013,Resident #1's care plan indicated she/he was to have two people provide peri-care services. Evidence and interviews indicated RP2 (CNA) provided Resident #1 care assistance alone on 10/02/2013. RP2 indicated at times that there are not two staff persons available to assist Resident #1 with her/his peri-care needs.,2,,Not Substantiated,Substantiated, +OR0000858101,385132,NF,10/16/2013,"Evidence and interviews indicated facility staff failed to ensure professional standards of practice were met in the area of assessing Resident #1's change of condition and/or notifying the physician in a timely manner when Resident #1 experienced a change of condition. The facility failure to provide Resident #1 the necessary care and services related to assessing a change in condition resulting in Resident #1 requiring hospital treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000719100,385133,NF,9/30/2011,"Resident 1 was admitted 2007 with multiple diagnoses. On 9/30/2011 Staff 4 (a nurse being oriented) gave Resident 1 insulin; resident did not take insulin. The resident was sent to the ER for evaluation and did not sustain negative effect, i.e.. Falling blood sugar. Staff 2 reported resident wrist bands are used and to be checked prior to giving medication. Staff 3 had stepped away after Staff 4 had drawn up insulin for another resident. Staff 4 reported he/she should have known to check the wrist band. Relevant portions of the survey are attached. Enforcement action for the facility was proposed. An Oregon Administrative Rule Violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000738400,385133,NF,1/5/2012,Resident 1 was admitted 11/29/2011 with diagnoses including a below the knee amputation. Resident 1 was to receive therapy services and was assessed a having poor balance. Resident 1's assessment indicated a need for a two person assist transfer using a gait belt or total lift transfer. Continued reassessment found Resident 1 improving and less assistance with transfers was required. Resident 1 reported falling on 1/2/2012 when he/she failed to lock the wheel chair brakes. Both Resident 1 and physical therapy were responsible to ensure the brakes were locked. Resident 1 sustained a non-injury fall representing a violation of Oregon Administrative Rule.,2,0,Not Substantiated,Substantiated, +OR0000800700,385133,NF,12/31/2012,"Resident 1 was admitted 2009 with diagnoses including dementia. On 12/28/2012 staff interpreted a specific physician dosing medication order as Zyprexa 25mg and transcribed the order as this. On 12/28/2012 the resident fell and sustained injury. The IDT notes of 12/29/2012 disclosed the physician stated the Zyprexa dose was 2.5mg; not 25mg. Multiple staff failed to recognize and or clarify the 25 mg dose as being out of range of dosing cautiously. Staff failed to note adverse reactions included abnormal gait, hypotension, etc. The resident sustained a preventable injury. Portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Neglect +OR0000840000,385133,NF,7/11/2013,"Resident 1 was admitted November 2011 with multiple diagnoses. Resident sustained a fall with fracture on 7/9/2013 during a lift transfer. Staff 1 and 2 cross checked the sling straps, but did not pull on the straps. Staff reported when the resident's feet were lifted to clear the bed edge, staff did not look at the strap loops. Reviewer noted a failed facility practice to in-service staff on visually checking sling straps any time the straps may loosen during a transfer. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +OR0000657100,385136,NF,12/27/2010,The facility failed to adequately assess and intervene when Resident #1 experienced a significant change of condition that contributed to Resident #1's death. Federal penalty recommended; relevant portions of the survey report are attached.,4,2500,Substantiated,Substantiated,Neglect +OR0000657101,385136,NF,12/27/2010,Evidence indicated facility failure to provide the necessary care and services to manage Resident #1 and Resident #4's pain. Federal penalty recommended; relevant portions of the survey report are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000688900,385136,NF,5/16/2011,"Evidence and interview indicated facility failed to provide adequate care plan interventions and services to prevent Resident #2's May 10, 2011 fall with injuries.",3,450,Substantiated,Substantiated,Neglect +OR0000689100,385136,NF,5/17/2011,Evidence and interview indicated facility failed to provide adequate care and services related to Resident #1's pressure ulcers.,3,450,Substantiated,Substantiated,Neglect +BC117203,385136,NF,6/10/2011,On 6/10/2011 Resident #1 became upset during a discussion with RP2 (licensed nurse). RP2 told Resident #1 she/he was acting like a four-year old. Resident #1 said she/he was really upset when RP2 told Resident #1 she/he was acting like a four-year old.,2,0,Not Substantiated,Substantiated, +OR0000720800,385136,NF,10/12/2011,"Resident #1 required extensive assistance with transfers and staff were supposed to use a gait belt with one person transfer assistance. Staff #6 (CNA) did not use a gait belt when assisting Resident #1 and was unable to transfer Resident #1 and lowered her/him to the floor. Staff #6 did not notify a nurse regarding Resident #1_x001A_s fall until three hours later, Resident #1 sustained a fracture. Relevant portions of the complaint investigation report are attached, federal penalty recommended.",3,0,Substantiated,Substantiated,Neglect +OR0000731000,385136,NF,11/29/2011,Evidence and interviews indicated facility failed to ensure care planned interventions were in place at the time of Resident #1's fall and facility failed to provide an adequate assessment of Resident #1 for injury after a fall. Resident #1 sustained a head injury and a delay in treatment. Federal penalty recommended relevant portions of survey complaint report are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000741100,385136,NF,1/24/2012,"Evidence and interviews indicated facility failed to ensure CNA's performed only duties within their scope of practice or under the direction of a nurse related to preparing and distributing hot pack treatments for Resident #1, resulting in Resident #1 sustaining a skin burn as a result. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,0,Substantiated,Substantiated,Neglect +OR0000829700,385136,NF,5/13/2013,Evidence and interviews indicated facility failure to ensure Resident #1 was assessed by personnel who had training and experience to complete an assessment. The failure placed Resident #1 at risk for unmet needs during the assessment. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +BC150099,385136,NF,1/16/2015,"Evidence and interviews indicated facility failure to provide a safe environment regarding Resident #1's theft of approximately $1,000 from her/his room by an unknown person on or about 1/16/2015. Evidence and interviews indicated Resident #1 preferred to keep her/his cash hidden in her/his room and that she/he declined offers to keep her/his money at a bank or in the facility safe.",2,,Not Substantiated,Substantiated, +BC150507,385136,NF,3/1/2015,"Evidence and interviews indicated facility failure to assure Resident #1's rights' when RP2 (CNA) declined to warm Resident #1's food at dinnertime without a thermometer to check food temperature on or about 3/1/2015. In addition, RP2 said, ""you make this place feel like a psych ward"" indicating her/his, comments were directed at facility staff. Witness #2 (facility staff) said she/he was standing nearby Resident #1's room when RP2 made the comment regarding a ""psych ward"" and witness #2 believed RP2 was directing the comment at Resident #1.",2,,Not Substantiated,Substantiated, +OR0000949000,385136,NF,2/13/2015,"Evidence and interviews indicated facility failure to assess, monitor, consistently treat and develop a comprehensive care plan for foot wounds for Resident #1 who had skin impairment. The failure to assess, monitor, treat and develop a comprehensive care plan for skin impairments placed Resident #1 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +BC151161,385136,NF,4/23/2015,Evidence and interviews indicated facility failure to assure Resident #1's rights related to an incident where RP2 (licensed nurse) reportedly grabbed the bill of Resident #1's hat and pulled it roughly down over Resident #1's eyes.,2,,Not Substantiated,Substantiated, +OR0000975100,385136,NF,6/9/2015,"Evidence and interviews indicated facility failure to provide adequate care and treatment services for Resident #1's pressure ulcer, which worsened, to a Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Resident #1 lost nine percent of her/his body weight and was hospitalized for treatment of the pressure ulcer. In addition, evidence and interviews indicated facility to identify Resident #1's change in condition when she/he experienced delirium. + + + +The facility failure to provide adequate care and treatment services related to Resident #1_x001A_s change in medical condition, resulting in Resident #1 sustaining severe weight loss, delirium and the development of a Stage 4 pressure ulcer, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +OR0000657600,385137,NF,12/28/2010,"Resident 1 was admitted 7/13/10 with multiple diagnoses and physician orders including therapy services. Resident 1's fall risk was assessed and revealed multiple factors including cognitive impairment, psychotropic medication, etc. Resident 1 fell the evening of his/her admission after ambulating without assistance. Staff give conflicting information regarding use of a personal alarm after this initial fall. Resident 1 was transferred to the hospital and re-admitted on 8/17/10 with identified fall risk and to use a personal alarm and motion detector. Resident 1 fell with injury on 8/21/10 with out indication that alarms were used and no update to the care plan occurred. On 8/31/10 Resident 1 was again found on the floor with injury requiring a trip to the hospital and a hip fracture was found. Resident 1 returned to the facility and sustained more falls without all the care plan fall interventions in place. Resident 1 sustained a subdural hematoma and was again re-admitted on 12/7/10 . The facility failed to follow Resident 1's care plan resulting in multiple falls with injury. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000658700,385137,NF,1/4/2011,"Resident 1 was admitted 2010 with multiple diagnoses including cognitive impairment and diabetes. On 7/13/10 P.M. staff found Resident 1 on the bathroom floor with a ""bump to the top of the head""; result of an unassisted transfer. Resident 1's progress notes did not include an assessment of the circumstances surrounding this event, time or date when physician was notified nor the family or other interventions/corrective action was taken to prevent further falls. On 8/21/10 at 6:40 P.M. Resident 1 was found on the bathroom floor with a ""large bump"" to the back of the head and complaints of pain at 4 of 10. Resident 1's assessment of 8/23/10 did not address the circumstance surrounding the fall or the effectiveness of the current care plan. Resident 1 sustained multiple falls between 10/27/10 and 12/4/10 without benefit of adequate assessment surrounding the incidents and or intervention for Resident 1's safety. Resident 1 sustained multiple falls with injury including a hip fracture and brain injury. The facility failed to follow it's own policy/procedure regarding accidents or incidents. The facility failed to ensure Resident 1 received adequate supervision and services to prevent accidents/incidents. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +KF116127,385137,NF,1/10/2011,RP2 failed to treat RV with all due respect by checking the inside of RV's brief for wetness. RP2 reported pulling the waist band out and the brief up to check for wetness; denies touching RV inappropriately. RP2 reported he/she usually works another area of the facility and does place hand inside brief to check for wetness which is contrary to what staff are taught per W2 . RP2 should have ensured that he/she obtained RV's permission before checking RV's brief.,2,0,Not Substantiated,Substantiated, +KF116357,385137,NF,2/14/2011,"On 2/14/11 RV requested staff to clean RV after a bowel movement and to change RV's bandage at the that time. RV reported it was 9:45 P.M. before RV was cleaned up and the bandage changed. RV reported usually bandage is changed at beginning of each shift and several times in between. W1 and W2 gave conflicting statements regarding change of shift report and need to change RV's bandages. W1 reported making a priority call; RV's vital signs were elevated and W1 was contacting RV's physician. W3 reported assisting RV to clean up at approximately 6: 30 P.M. or 7:00 P.M., but he/she changed his/her statement later. As of 2/15/11 a care conference notes showed RV's wound is doing well, getting smaller, etc. RV did not receive timely treatment/care and was at risk for harm.",2,0,Not Substantiated,Substantiated, +KF103702,385137,NF,3/4/2010,"RP2 reported RV was connected to a E-tank for oxygen and was planning to switch to the concentrator later in the shift. W6, 8 and 9 give differing stories as to when RV's oxygen tubing was connected. RV has a history of sudden desaturation with his/her oxygen levels dropping despite continuous oxygen application. RV was not properly attached to oxygen on 3/4/10 and 3/24 or 3/25/10. RV was at risk for harm.",2,0,Not Substantiated,Substantiated, +KF120641,385137,NF,7/26/2012,"The complainant voiced multiple concerns regarding staff not assisting RV with food and drink. The investigator observed untouched breakfast tray and clean silverware at RV's bedside at 11:00 A.M. on 7/27/2012. W1 and W2 reported RV's overall health has declined and RV is on comfort care measures. W2 and W4 reported observing untouched food at RV's bedside or laying of food on RV's stomach wand staff walking out of the room. W3 denied anyone voicing concerns, but staff are not to leave food with RV unless they are assisting RV to eat. Staff failed to follow RV's care plan . An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000823900,385137,NF,4/15/2013,Resident 1 sustained a change of condition on 3/2/13 and the physician was notified on 3/3/13 with treatment orders received. The resident continued to exhibit a change of condition including shortness of breath with exertion and signs of a UTI without documented physician notification. The resident was sent to the hospital on 3/13/13. The facility failed to provide documented physician notification of resident change of condition. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +KF133350B,385137,NF,5/29/2013,"RV reported receiving a pain pill every 4 hours or as RV requests, but sometimes staff gets busy and forgets. RV reported having family voice concerns and they (staff) have been pretty good about it. Review days where RV did not receive pain medication or the pain assessment went beyond 10 hours placing RV at risk for increased discomfort. An Oregon Administrative Rule violation occurred..",2,,Not Substantiated,Substantiated, +KF133350C,385137,NF,5/29/2013,"RV's care plan addresses transfers and skin risks. RV, witnesses and documentation give conflicting information as to whether staff always provide a two person transfer. RV was wearing short sleeves at the time of RV's injury; it was warm. The facility has ordered Geri sleeves to protect RV's arms so RV does not have wear long sleeves all the time. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +KF149032,385137,NF,10/24/2014,"The complainant reported RP2 made inappropriate comments to RV1, 2 and 3. RV1, 2 and 3 are unable to give much in the way of relevant information. RV1 did say during interview that a person as the same sex at RP was curt with RV1. RP2 denied saying anything wrong to any resident; RP2 reported may have sworn around RVs, but not at them. RP2 may have used profanity around residents, but evidence is inconclusive RP2 swore at residents. The facility failed to ensure residents were treated with all due respect.",2,,Not Substantiated,Substantiated, +MS150278,385137,NF,2/17/2015,"On February 12, 2015 the facility failed to have an adequate oxygen supply to meet resident needs in general; and RV1 and RV2's need in particular. RV1's hospital admission/transfer information included general information to keep RV1's oxygen saturation above 90%. On 2/12/2015 at approximately 7:30 P.M. RV1 exhibited a change of condition with oxygen saturation at 83% which required application of oxygen. The facility did not have additional oxygen tanks or concentrators on hand to immediately supply RV1 with oxygen. Staff took an oxygen tank RV2 was using and gave it to RV1 to use. RV2 was placed in bed to use his/her in room oxygen concentrator as RV2 required oxygen in and out of bed. Consequently since RV2 required oxygen while out of bed and no tank was available to RV2; RV2 was essentially bed bound and RV2's choice in his/her care was not honored. W3 and W4 (facility administrative staff) reported knowledge the facility did not have additional oxygen tanks and concentrators, yet failed to obtain and or ensure oxygen was immediately available to RV1 or any resident who required emergent oxygen use. The facility's failure to have adequate oxygen tanks and or concentrators for immediate use resulted in neglect of care which constitutes abuse. Oregon Administrative Rule violation occurred.",3,300,Substantiated,Substantiated,Neglect +OR0000955201,385137,NF,3/17/2015,"Repeat facility failure to provide medication as physician ordered resulting in potential for harm. Resident 4 was admitted in March 2015 with multiple diagnoses. The residents hospital discharge medication list indicated the resident received Oxycodone at 9:16 A.M., but not the scheduled Lidocaine. The resident's facility physician orders included specific medication orders including orders for Oxycodone and Lidocaine. The resident assessment dated 3/11/2015 at 1:24 P.M. indicated the resident's back pain at 8 out of 10. The resident did not receive the scheduled Oxycodone for 8:00 P.M. 3/11/2015 or the 8:00 A.M. dose on 3/12/2015 due to the medication not being available per documentation. The resident did receive PRN Dilaudid and the resident indicated it helped some. The resident did not receive the scheduled Lidocaine until 7:00 P.M. on 3/13/2015. The facility failed to inform the physician or the pharmacy regarding medication unavailability. The resident went a number of days without his/her scheduled pain reducing medication which placed the resident at risk for increasing pain and or discomfort. The facility failed to have an adequate medication system in place to ensure resident's received physician ordered medication and or the physician was notified promptly when medication was unavailable. Relevant portions of the survey are attached. Oregon Administrative Rule violations occurred.",2,250,Not Substantiated,Substantiated, +KF150753,385137,NF,3/29/2015,"RV1 and RV2 have cognitive impairment and known behaviors. A physical altercation between RV1 and RV2 occurred when RV2 with a known infection and progressive confusion, anxiety and aggression slapped RV1. The facility failed to care plan and or provide adequate interventions to address RV2's behaviors. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000995700,385137,NF,8/20/2015,"Resident 81 was admitted 7/27/2015 with multiple diagnoses including post hip fracture and dementia. The resident assessment determined the resident was a fall risk and was to be kept in an area of observation and monitoring. Resident's 7/27/2015 care plan interventions included visual checks to see if the resident was restless or needed assistance. On 8/18/2015 Staff 14 left the resident alone in the shower room for approximately two minutes to get the nurse to apply rash medication. While resident's care plan did not specifically state not to leave the resident alone in the shower, Staff 14 used poor judgment in not using the call light to summon another staff; thinking it was faster to leave the resident alone for even a very short period of time while getting the nurse. The resident fell and sustained a left hip fracture. Staff 14 received further education. Relevant portions of the survey are attached. Enforcement action toward the facility was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000999501,385137,NF,9/3/2015,Resident 28 was admitted 2015 with diagnoses including COPD. The resident's 7/29/2015 care plan revealed physician ordered oxygen with the 8/9/2015 MDS noting the resident did receive oxygen therapy. Record review of October's MAR and TAR did not reveal physician ordered parameters for use of the oxygen. The resident was placed at risk for harm. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +RD117813A,385138,NF,8/2/2011,"RV was admitted 7/18/11 following hospitalization and surgery for infections. Evidence supports failure to ensure a medication system was in place to assure RV received necessary PRN medication. Given RV's infection that was not resolving, evidence is insufficient to support increased pain due to failure to provide PRN medication without RV requesting the medication. The facility should have provided on going pain assessment with interventions including explaining PRN medication request in a more timely manner. Staff contacted RV's physician regarding RV's pain and pain patch was initiated. RV was seen by the neurologist on 8/2/11 and returned to the hospital.",2,0,Not Substantiated,Substantiated, +BO135261,385138,NF,10/21/2013,"RV reported RP2 was in a hurry, yelled/cussed at RV, grabbed RV's arm to roll RV and caused pain on a scale of 1 to 10 at a ""10"". W1 and W2 reported RP2 ""grabbed"" RV's arm and cussed at RV causing RV to become upset. W1 and W2 directed RP2 to leave the room. RP2 reported ""I said this is fucking ridiculous"", pulled away from RV and walked off. RP2's rough actions toward RV, as well as, cussing at RV constitute physical and verbal abuse. The facility took prompt and appropriate action to protect RV and other residents from future harm. An Oregon Administrative Rule violation occurred.",3,,Not Substantiated,Substantiated,Physical Abuse +BO152049,385138,NF,6/22/2015,"RP2 transported RV per wheel chair van, detached two straps, realized he/she was at the wrong entrance and transported RV around the corner to the other entrance without reattaching the other two straps. RV's wheel chair tipped over and RV fell without noted injury. RP2 has driven for the facility for 1/2 years without incident. RP2 readily admitted to misjudgment. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0001008000,385138,NF,9/25/2015,"Resident 1 was re-admitted 9/2015 with multiple diagnoses including chronic kidney disease and diabetes mellitus. Resident's admission profile dated 9/4/2015 indicated the resident was alert, oriented, no obvious bowel problems; an right below knee a left toe amputations. The form was incomplete and inaccurate regarding pulse on the right foot. The resident sustained looses stools a number of days beginning 9/8/2015; sample taken 9/12/15 with results returned to the facility on 9/13/15 indicating positive for c- difficile, but staff wrote negative in resident 's progress notes. Further inaccurate documentation occurred and the resident was discharged without treatment for the c-difficile. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000674800,385141,NF,3/11/2011,"Staff left Resident 1 alone on the bedside commode, although Resident 1's care plan called for a one person assist for transfers, walking. Staff did apply Resident 1's alarm and stated telling a co-worker to keep an eye on Resident 1. Staff reported the co-worker had not heard and or understood the request. Staff heard the alarm and found Resident 1 without injury on the bedroom floor. Staff 1 received counseling and knew it was facility policy not to leave a fall risk resident alone on the commode.",2,0,Not Substantiated,Substantiated, +BC118006,385141,NF,9/14/2011,"RV1, RV3, RV4 and RV5 deny any problems; received medication. RV2 was unable to give relevant information. Resident 4 had not been reporting increased pain. W1, W2, W3, W4, W5 and W6 reported narcotic discrepancies. On 9/12/11 W2 and W4 interviewed RP2 and RP2 admitted diverting PRN narcotic medication from several residents. RP2 was provided counseling, suspension and Oregon State Board of Nursing was notified, as well as, law enforcement and the local SPD. The facility has implemented new procedures to help prevent medication diversion.",2,0,Not Substantiated,Substantiated,Financial abuse +BC120034A,385141,NF,5/8/2012,"The complainant report RV did not receive his/her pureed diet or receive 1:1 assistance with eating on several occasions. The complainant gave several other concerns. Staff reported RV did not have a pureed diet at admission, but received a pureed diet after a swallow assessment. RV receive IV hydration therapy and was sent to a new facility with IV. Staff believe Hospice was to follow up. W3 reported finding RV with the wrong diet approximately 2 to 3 times. Staff and W3 agree difficulty in obtaining a special functioning bed. W3 reported if she/he remembered correctly it was the bottom half of the bed that did not function; not the top half. W6 reported staff did follow isolation technique. Kitchen staff were reminded to pay attention to details with resident meal trays.",2,0,Not Substantiated,Substantiated, +OR0000815200,385141,NF,3/4/2013,"Resident 1 was admitted 2013 with multiple diagnoses including paranoia, etc. Resident care plan dated 1/12/2013 indicated resident wish to remain as independent as possible. The resident required a one person assist with transfers and used non skid mats and non skid sock. Resident 1 was found on the floor on 2/24/2012 after attempted self transfer. Resident care plan was in place at the time. Resident 2 was part of an extended resident survey in connection with this investigation. Resident 2's care plan indicated fall risk; not to be alone on the toilet or commode. Resident fell on 3/8/2013 after Staff 5 read a clip board of residents not to be alone on the toilet, did not find Resident 2's name on the board and left the resident alone. Resident sustained superficial abrasions. The facility provide further in-service, all staff meeting to review QA/QI and weekly audits time 4. relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rules were violated.",2,0,Not Substantiated,Substantiated, +BC134775B,385141,NF,10/10/2013,The complainant reported RV received the wrong medication and RV received double pain patch. W1 reported RV did receive a medication in error on 8/28/2013 without noted side effect. W1 reported pain patches are removed before a new patch is applied. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +BC147400,385141,NF,6/2/2014,RP2 admitted diverting narcotics for RP2's personal use from multiple residents including RV1 and RV2. The facility found narcotic record discrepancies while completing their internal record review. The facility took immediate action by questioning RP2 (who admitted taking the medication); immediately reporting their findings to OSBN and other pertinent agencies; terminating RP2's employment and starting reimbursement to the effected residents. RV1 and RV2 did receive pain medication. RP2's theft of resident medication constitutes abuse. Oregon Administrative Rule violations occurred.,3,,Not Substantiated,Substantiated,Financial abuse +OR0000669300,385142,NF,2/15/2011,"Resident 1 was admitted December 2010 with diagnoses including Alzheimer's. Staff 4 observed W1 tell Resident 1 in a loud voice not to hit W1, observed W1 push on Resident 1's shoulders to sit back in the wheel chair and hold Resident 1's arms on the wheel chair. Staff 4 and Staff 1 give conflicting statements regarding the event. Staff 1 intervened. W1 when asked about the incident stated ""it could have"" occurred. The facility suspended and terminated W1's employment. Nursing staff was re-educated regarding reporting abuse or alleged abuse. Relevant portions of the survey are attached.",2,0,Substantiated,Substantiated,Neglect +OR0000669301,385142,NF,2/15/2011,Staff failed to promptly report possible abuse of Resident 1. When staff did report the facility terminated W1's employment. Resident 1 and all residents were at risk when W1 was not suspended or promptly reported for alleged abuse. Relevant portions of the survey are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000680000,385142,NF,4/4/2011,"Resident 1 was admitted in 2011 with diagnoses including a stroke. Resident 1's fall assessment of 3/15/2011 indicated a risk for falls and care plan interventions o 3/18/2011 included a low bed and alarms while Resident 1was in bed. On 3/28/2011 Resident 1's physician ordered an alarm in bed and in the wheel chair. On 4/1/2011 Staff 2 ""forgot"" to turn the bed alarm back on and Resident 1 was found on the floor with facial and head injury. Staff 3 observed Resident 1 shortly before the incident and Resident 1 was sitting on the bedside, but Staff 3 was unable to get to Resident 1 before Resident 1 fell. Reviewer notes that alarms in and of themselves will not prevent all falls. Had the alarm sounded Resident 1 may still have fallen before staff could intervene. Nursing staff received further in-service and residents will be monitored to ensure fall preventions devices are in place. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +FL116353,385142,NF,1/29/2011,"Evidence fails to support rough care, RP2 did fail to support RV's Residents Rights by removing RV's fingers from the side bar/hand rail, rather that re-approaching RV. RV had no sign of injury. RP2 had received previous warnings regarding his/her treatment of residents. The facility failed to ensure all residents were treated with respect and received all care and services. The facility ultimately terminated RP2's employment.",2,0,Not Substantiated,Substantiated, +OR0000685801,385142,NF,4/27/2011,"Resident 4 was admitted 122310 with multiple diagnoses. Resident 4 was transferred to the hospital on 1/27/11 for further evaluation of cognitive changes and refusal to follow the physician's plan of care. I8nitially staff refused to re-admit Resident 4, but allowed the readmission after speaking with a representative from the state nursing facility program. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +OR0000721400,385142,NF,10/18/2011,"Resident 2 was admitted 10-12-11 with multiple diagnoses and physician orders including intermittent catheterization. Resident 2 self catheterized. On 10/13/11 Resident 2 developed dark urine, but staff failed to notify the physician in a timely manner. On 10/15/11 Resident 2 sustained a change of condition, physician was notified and Resident 2 was transferred to the hospital. Resident 2 had an elevated temperature for three shifts on 10/14/11. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +ES129160,385142,NF,2/1/2012,"RV's incontinence brief was checked at 6:00 A.M. and RV was then found in a wet brief at 1:30 P.M. While RP3 asked RV if RV needed to toilet, RP3 did not take RV (who is cognitively impaired) to the toilet. RP3 was counseled and further in-service regarding memory care residents was given. RV was at risk for skin issues, but no negative outcomes were found. Evidence is inconclusive how long RV was wet. Staff failed to follow RV' care plan resulting in a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +FL120183,385142,NF,5/30/2012,"Staff were busy with another resident, but observed RV1 enter the dining room. Staff observed/heard RV1 approach RV2 and found RV1 holding RV2's arm. It took multiple staff to get RV1 to let go of RV'2 arm. RV2 sustained a bruised arm. Staff failed to redirect RV1 away from RV2 in a timely manner resulting in RV2's injury. Neither RV were able to remember the event. The facility failed to ensure a safe environment for RV1 and RV2. this failure constitutes abuse and an Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +OR0000745200,385142,NF,2/15/2012,"Resident 65 was admitted to the Memory Care Unit on 1-24-12 after hospitalization for edema and other diagnoses. The resident's physician ordered Lasix and KCl with an increase in both on 1/27/12. on 3/9/12 the physician lowered the Lasix, but the KCL and ordered lab work a week later; noted typo as lab was drawn 3/15/12. The resident was sent to the ER per his/her physician when the labs came back as critical levels for the KCL. Witness/staff reported would have expected staff to question lowering the KCL when the Lasix was lowered. An ER note indicated suspicion the resident was not eating or drinking properly contributing to the resident's mental status. The facility failed to properly monitor the resident's over all condition change. Relevant portions of the survey are attached. A federal civil penalty was recommended. An Oregon Administrative Rule was violated.",3,0,Substantiated,Substantiated,Neglect +OR0000748201,385142,NF,3/5/2012,The facility failed to have sufficient staff in particular at night. On 6/12/12 Resident 26 was left unattended in his/her wheel chair while staff sought other staff assistance; staff returned to find the resident on the floor. On 6/13/2012 at 7:45 P.M. surveyors observed no staff were in the dining room while residents were eating. On 6/13/2012 surveyors observed residents enter other resident rooms without staff present for re-direction. On 6/14/2012 a surveyor stood by Resident 20 who had stood up and required assistance until staff arrived to assist. Resident 20's alarm was not in place. Residents were at risk due to insufficient staffing. Relevant portions of the survey are attached. An Oregon Administrative Rule was violated.,2,0,Not Substantiated,Substantiated, +OR0000752000,385142,NF,3/26/2012,"Resident 65 was admitted in 2011 with multiple diagnoses and care plan interventions addressing diabetes to include meal monitoring, check CBGs and giving Insulin with certain goals. On 2/8/2012 the resident was given Insulin prior to lunch as physician ordered, but resident refused to eat lunch. Staff did not monitor resident CBGs, offer meal replacement or snack. The resident was found unresponsive at 4:05 P.M., staff gave Glucagon, notified the physician and transferred the resident to the ER. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule was violated.",3,0,Substantiated,Substantiated,Neglect +OR0000752001,385142,NF,3/26/2012,"Resident 65 was admitted in 2011 with multiple diagnoses and care plan interventions addressing diabetes + +to include meal monitoring, check CBGs and giving Insulin with certain goals. Resident was re-admitted on 1/24/2012 following hospitalization for edema and other diagnoses including CHF, dementia and aggression. Resident's Lasix and potassium was increased on 2/3/2012. On 3/9/2012 the Lasix was lowered, but not the potassium. The resident received lab work a week later and the physician sent the resident to the hospital with critical labs indicating high levels of potassium. Staff failed to adequately inquire to lower the resident potassium when the resident's Lasix was lowered. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule was violated.",3,0,Substantiated,Substantiated,Neglect +OR0000752002,385142,NF,3/26/2012,"The facility failed to provide adequate staff for the memory care unit. On 6/13/12 between 7:45 and 8:06 surveyors found Resident 65 seated on the edge of the bed wearing only a brief, yelling for help. Resident 35 next door went to the doorway, looked down the hallway and was softly calling out. Staff responded at 8:06. Relevant portions of the survey are attached. Oregon Administrative Rule was violated.",2,0,Not Substantiated,Substantiated, +OR0000768000,385142,NF,6/20/2012,"Resident 1, a long term resident, was care planned as a high fall risk with multiple interventions in place as of 8/15/2012 including use of an alarm. On 6/15/2012 the resident was found on the floor; staff were unable to state whether or not the resident alarm had been activated. Staff deny hearing the alarm at the time the resident was found not eh floor. The resident sustained minor injury. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +FL120860,385142,NF,2/28/2012,RV1 gave multiple concerns; predominantly was told to go in the bed and was yelled at when soiling the bed. RV reported it took over half an hour to get help to clean up incontinence issue. RV did not tell administrative staff that it took over half an hour for staff to respond to the call light. The facility failed to address over counter medication for appetite in a timely manner. RV's care plan did not address the reason for the nutrition risk. RV required transfer assistance and did not receive assistance resulting in an incontinence episode. No nursing assessment or care plan did not address altered continence. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000825400,385142,NF,4/23/2013,Resident 1 was admitted 4/4/13 with diagnoses including respiratory failure. Physician orders included use of a BiPAP machine set at specific levels and oxygen saturation at or above 88 to 89%. The resident had orders for oxygen at different levels. The resident did not receive all treatment as ordered. Relevant survey pages are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +FL133810,385142,NF,7/9/2013,RV had good recall and did not exhibit anxiety when speaking of RP2's comments. During an emergency drill RP2 told RV to shut his/her mouth. The facility reported RP2's less than respectful comments to APS and OSBN. RV did not sustain notable harm. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +FL120754,385142,NF,8/6/2012,Staff failed to follow RV2's care plan. RV1 and RV2 engaged in a physical and verbal altercation without staff present to promptly intervene resulting in RV1 sustaining a skin tear to his/her arm. There were two more interactions approximately two months previously. Staff are now providing one to one supervision for RV2 while working on an alternative placement. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Neglect +FL134082,385142,NF,8/7/2013,"RP2 wrote a note to RV, showed RV, W3 and W4 the note which stated ""why are you such a bitch"". RP2 gave conflicting statements regarding RP2's actions, but W3 and W4 reported RP2 did show them the note while reporting RP2 had shown the note to RV. RV has no recollection of being shown the note, but a reasonable person would perceive RP2's written communication as emotionally harmful. RP2 had received abuse training at the facility prior to this event. The facility took immediate action to protect RV and other residents from future harm. An Oregon Administrative Rule violation occurred.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +FL135316A,385142,NF,12/1/2013,"The complainant and RV reported RV was not bathed in a timely manner. RV reported bathing self so he/she ""would not stink"" when going to a physician appointment. RV is now scheduled to bath Monday and Thursday; preferring AM baths. Record review between 11/26 and 30/2013 did not show any initials for bathing. The December ADL also showed scheduled shower days not all initialed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +FL150495,385142,NF,3/8/2015,"RP2 took RV into the shower room and closed the door to allow RV privacy to undress. RP2 and witnesses report RV did yell ""let me out"" and RV struck the door causing the door to shake. RV initially told RP2 RV did not want to take a shower, but then agreed to shower before RP2 took RV to the shower room. Witnesses reported RP2 did not open the door. Witnesses report RV was in the shower room at least five minutes, but there is no mention of how this was timed and or why witnesses did not intervene. W3 heard RP2 tell RV ""you're taking a shower"" multiple times and telling RV ""no, you're taking a one now"". RP2 reported at the informal conference (held 5/20/2015) that RP2 was just trying to help RV after RP2 heard the nurses talking about how RV needed to shower. RP2 reported directing the new C.N.A. to go assist another C.N.A. and telling the NA assigned to RV to go in and help RV. RP2 told an off duty NA to go about the NA's business. RP2 demonstrated/ reported how witnesses observing RP2 could mis-interpret RP2 leaning on the rail at the door as RP2 possibly holding the door, but RP2 denied keeping the door shut as it opened inward to the shower room. RV reported being mad and that RP2 was not fair. RV was not fully given a full choice in his/her care. The facility took immediate and appropriate action to provide safety for RV and other residents. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Involuntary Seclusion +FL149070,385142,NF,4/15/2014,"RV voiced concerns, but RV's primary concern was RV receiving two doses of Insulin at the same time. RV reported being stressed and anxious, ate sugary food and did not experience harm. RV's June MARs was not accurate; W3 checked the May MAR and physician orders; found the error; notified the PCP and RV was monitored the rest of the day. The facility failed to ensure a safe medication system resulting in a medication error and risk of harm to RV. Oregon Administrative Rule violation occurred..",2,,Not Substantiated,Substantiated, +OR0000953800,385142,NF,3/11/2015,"Based on interview and record review it was determined the facility failed to comprehensively assess, provide estimated fluid needs and failed to monitor all fluid intake and output to maintain hydration status. Resident 1 was admitted 2014 with multiple diagnoses including chronic kidney disease, diabetes and stroke. Resident's ADL CAA dated 9/23/2014 identified nutritional and fluid risks. Between 2/12/2015 through 3/1/2015 resident's clinical record revealed no nursing notes regarding resident's refusal of supplements and or fluid intake of less than 1600 cc's. The resident's vital signs sheet revealed no daily documentation of vital signs or oxygen saturation after 1/2/2105. the resident's ADL flow sheet for 3/2/2015 indicated the resident slept all shift, refused all meals and did not indicate the resident's urine was dark colored. The resident was sent to the hospital on 3/2/2015 and diagnosed with acute kidney injury secondary to dehydration and UTI. Relevant portions of the survey re attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000762300,385143,NF,5/21/2012,"Resident 1 was admitted April 2012 with multiple diagnoses. Resident care plan dated 4/17/2012 indicated fall risk with multiple interventions implemented including use of alarms. The bedside care plan indicated tab alarm for safety. On 5/5/2012 the resident removed the alarm, rose from the toilet and fell sustain a scalp laceration. The resident care plan was updated to place the alarm out of reach. The resident fell on 5/17/2012 while in his/her room without the tab alarm in place. Staff was not interviewed as they had moved out of state. The facility investigation revealed the resident complained of back pain and the resident was sent to the ER; no additional injuries were found. Staff 3 reported new interventions were added to include one alarm attached to the recliner and one for the wheel chair. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +OR0000799700,385143,NF,12/21/2012,"Resident 1 was admitted in 2004 with multiple diagnoses. Resident 1's face sheet identified the resident as his/her own responsible party and a second contact as W1. W1 expressed concern regarding facility communication. Resident 1 experienced severe back pain and W1 was notified, but staff failed to notify W1 of the resident's hospitalization of 12/6/2012. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +RB133083A,385143,NF,4/20/2013,"W1 reported during dinner RV wanted pain medication, assistance to bed at 5:20 P.M. and again at 5:30 P.M. with RV receiving pain medication at 5:50 P.M. RV's pain medication was delayed by approximately 30 minutes. W3 reported being at lunch and gave the medication as soon as he/she returned. Witnesses reported the facility was short staffed and may have contributed to the delay in RV receiving requested assistance and medication. The delay in receiving pain medication would cause an additional amount of time RV was in pain. The additional time represents minor harm and abuse. An Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Neglect +RS133145,385143,NF,5/5/2013,"RV eloped from the facility on 5/5/2013 at approximately 7:30 P.M. Witnesses reported RV had been upset and on 15 minute visual checks and if RV was observed near an exit RV was redirected. The facility implemented protocol when RV was found AMA. The documentation noted RV was checked at 6:45 P.M., but staff reported seeing RV at 7:15 P.M. as an alarm had gone off. W3 reported RV can be very fast. Staff were aware at 7:00 P.M. RV wanted to go out to smoke. Given RV's behaviors the event was foreseeable. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +RB133472,385143,NF,4/18/2013,"The complainant reported an on going issue with RV sustaining cuts from nails being too long. W1 reported now care is not being completed often enough; staff state RV refuses. Witnesses reported RV refuses to use arm protectors. RV's 2/15/2013 care plan indicates skin risk with interventions. RV's in room care plan noted speech, skin and dressing needs including RV saying no when RV means yes. RV did sustain asking tear to the left arm on 3/18 and 4/27/2013. while some interventions were in place, the facility did fail to provide adequate care and services to prevent recurring skin tears. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +RS133348,385143,NF,5/29/2013,Staff failed to adequately communicate RV's left ear skin change. RV did not receive treatment until 5/31/2013 as W3 was unaware of RV's skin issue until that time. RV was at risk for harm an Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +RB133166B,385143,NF,5/5/2013,"RP2 denied understood RV was a two person for changing, but not for transfers. RV's in room care plan dated 4/27/13 noted two people in room at all times. RV's care plan was not followed.",2,,Not Substantiated,Substantiated, +RB135131,385143,NF,10/16/2013,Staff failed to provide nail care two times per month as care planned during October 2013. RV sustained skin tears were consistent with RV's nails puncturing RV's skin during repositioning. The resident skin tears were due to lack of nail care. Staff obtained body fluids using an old physician order. Staff should have obtained new orders. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +RS147659A,385143,NF,4/28/2014,"RV was admitted on 4/16/2014 and re-admitted 4/28/2014. RV's personal belongings listed effects including a wallet, credit cards and money. The belongings list did not have a date listed. RV's monies were lost; date and origin unknown. The facility replaced the monies and provided RV with a safe. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Financial abuse +RB148735,385143,NF,9/26/2014,RV1 touched RV2's chest as RV2 wheeled by RV1. W1 reported RV1 has a history of similar behaviors. Staff have held several conversations with RV1. staff are providing frequent visual check of RV1. RV1 is now on 15 minute checks. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +RB149540,385143,NF,12/7/2014,"W1 reported RV1 is still at it. The facility failed to reassess and prevent RV1 targeting RV2. RV2 does not like RV1, but does not remember that RV1 touched RV2. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +RB159999A,385143,NF,11/14/2014,"The complainant reported RP2 was told of RV's odor and possible infection on 12/28/2014, but RP2 failed to notify RV's physician. W1 and 2 deny knowledge of RV having an odor or possible medical condition. RP2 acknowledge RV's family did come with concerns, attempted a urine catch, became busy, is not sure the information was passed and failed to document the events. Witnesses deny RP2 told of the family's concerns and there was no documentation. RV was placed at risk for further harm. Oregon Administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +RB159999B,385143,NF,11/14/2014,"W6 was a traveling therapist and spoke with RV's family, but failed to notify W2 of the request for a lower bed. W5 reported RV's transfers were difficult without a lower bed. W2 learned of the lower bed request on 12/10/2014 and the bed was brought in on 12/11/2014. There was a delay in obtaining RV's requested lower bed due to poor communication.",2,,Not Substantiated,Substantiated, +OR0000932101,385143,NF,11/5/2014,"Resident 71 was admitted September 2014 with diagnoses including a fractured arm, syncope and coronary artery disease. The resident care plan dated 9/26/2014 indicated use of a personal alarm at all times and remind the resident to use the call light. The resident MDS dated 10/2/2014 documented the resident occasionally rejected care and required extensive assistance of two staff for transfers. The resident failed to use his/her call light on 10/20/2014 and fell attempting a self transfer resulting in abrasions to his her face. Although alarms in and of themselves will not prevent all falls, no alarm was attached to the bed side commode. The facility failed to ensure alarms were attached to the bedside commode, as well as to the bed and wheel chair. Relevant survey pages are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +RS150519,385143,NF,3/6/2015,"RP2 told RV he/she could not return to a medical facility without an escort due to RV's behaviors. RV denied any wrong doing and did not want to ""go there"" anymore. RV became ""upset"" over what RP2 said. RP2's repeating to RV what was reported to RP2 upset RV. RP2 failed to allow RV a choice in RV's care; no care plan was developed to address RV's behavior; and RV was not treated with all due respect.",2,,Not Substantiated,Substantiated, +RS152882,385143,NF,8/13/2015,"The facility failed to ensure a safe environment resulting in an outsider unknown to facility staff (RP2) to enter the facility and inappropriately touch RV1's upper body. Additionally RP2 entered another resident's room resulting in the other resident screaming. W2 (staff) reported the front door/exit was left open to allow visitors in for family night. The facility failed to have an alarm system in place and or other means such as direct visual observation of the front door to secure the entrance and exit from the facility. Additionally while W2 spoke to RV1, W2 failed to speak with LEA directly and failed to thoroughly investigate or document the event. The facility's failure to provide a safe environment in which RV1 was touched in a personal manner without RV1's permission and which caused a significant loss of dignity; did result in neglect and abuse. Oregon Administrative Rule violation occurred.",3,250,Substantiated,Substantiated,Neglect +OR0000979500,385143,NF,7/8/2015,"Resident 1 was admitted June 2015 with multiple diagnoses including Alzheimer's and a right hip fracture due to a fall. The resident's initial data collection form identified fall risk factors. The 6/12/2015 temporary care plan noted interventions including use of a Tab Alarm in bed and the wheel chair. The resident sustained a fall on 6/22/2015 after removing the alarm his/he shirt with the alarm attached. The resident sustained a hematoma. The facility failed to document and or investigate the fall and failed to provide further action to prevent a recurrence. The resident sustained another fall on 7/3/2015 without documentation of investigation. While the nurse noted the use of a pressure alarm; the resident's care plan was not updated to include the pressure alarm the resident repeatedly set off the alarm with out further invention and the resident fell on 7/7/2015 with injury. Documentation indicate use of the tab alarm from 8/9 through 8/13 , but not the pressure alarm. The facility failure to ensure care and services resulting in repeated injury falls constitutes abuse through neglect of care. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000991400,385143,NF,8/11/2015,"Resident 2 was admitted 8/6/2015 with diagnoses including Left leg patella fracture with a leg immobilizer in place. The resident's temporary care plan indicated two CNAs for transfer. The resident fell forward from a shower chair on 8/7/2015 and sustained an injury requiring hospitalization for a fracture. The facility failed to thoroughly investigate the event and or fully document how/shy the event occurred. Staff reported the shower chair brakes did not hold. Staff stated the shower chairs are checked monthly, but was unaware of the resident's fall from the chair or the chair brakes were not working. Staff acknowledge the incident reports were Incomplete. The resident gave conflicting statements; stated was not in the chair at time of the fall. The facility failed to provide adequate care and services resulting the resident's fall with injury. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +RS164336B,385143,NF,1/6/2016,"RV was assessed and care planned as continent, one person assist and a pad for dignity. Record review and witness interview determined RV did not receive timely assistance, RV sustained a bladder accident and staff failed to assist with cleaning RV or the floor in a timely manner. W2 assisted RV with incontinence care and wiped the floor. RV was tearful at times during the interview regarding this allegation. RV's significant loss of dignity constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +AS105731,385144,NF,11/9/2010,"RP2 failed to treat RV with all due respect and consideration. RP2 reported the incident occurred near shift change, it was busy and call lights were going off. RP2 reported thinking RV1 and RV1 understood there were others ahead of them. RV1 reported ""RP2 spouted off, well you did it yourself last night , you can do it tonight"" when RV 2 asked for help. RV2 reported RP2 ""does not think before speaking"". RV2 described RP2 as young and inexperienced. The facility incident report revealed both RV1 and RV2 were okay with RP2 as a care giver. There were no other negative comments from other residents. RP2 was reassigned for increased supervision and training.",2,0,Not Substantiated,Substantiated, +OR0000673900,385144,NF,3/4/2011,"Evidence and interview indicated facility failed to develop and implement care plan interventions for Resident #1 who was assessed as a high fall risk. February 7, 2011 nursing notes indicated Resident #1 was found on the bathroom floor, sent to the hospital and diagnosed with a fractured femur. Federal civil penalty recommended; relevant portions of the survey report are attached.",3,0,Substantiated,Substantiated,Neglect +AS118496,385144,NF,11/17/2011,"W1 and W2 reported RV was missing restorative therapy. RV did not receive all restorative therapy as care planned. A physician telephone order date 7/15/11 reported no skilled services, but remain on restorative care. RV confirmed not receiving restorative therapy 5 days per week and he/she likes the sessions. The service did show as elective, but recommended by RV's physician. W1, 2 and 3 all reported staff duties are to the floor first and then to restorative care. Review of the facility policy did not indicate the program was elective or came in second to floor staffing needs. RV did not receive all the restorative care as care planned.",2,0,Not Substantiated,Substantiated, +AS129013,385144,NF,12/31/2011,RP2 began a medical procedure without waking RV or advising RV of the procedure. RV awoke and was frightened and yelled at RP2 to stop and leave the room. RP2 continued with the procedure against RV's wishes. RV threatened to spit on RP2 and RP2 threw RV's sheet over RV's face. RV was unable to use his/her extremities to remove the sheet. RV reported being upset when RP2 failed to stop providing care at RV's request and when RP2 placed a sheet over RV's face. RP2 failed to provide RV with choice in RV's care and failed to treat RV with respect and dignity when placing a sheet over RV's face. RP2's actions resulted in a serious loss of human dignity and constituted abuse.,2,0,Not Substantiated,Substantiated,Neglect +AS129876,385144,NF,4/7/2012,"Nursing notes dated 3/13/2012 to 4/9/2012 revealed RV attempted several times to self transfer without requesting assistance resulting in falls with and without injury. Various interventions were care planned, but not consistently utilized. Alarms were either disconnected or not activated. Staff reported alarms were connected and or turned on prior to RV's falls, but alarms did not sound. While alarms in and of themselves will not prevent all falls, they must be consistently implemented or other care planned interventions adopted to alert staff to RV's attempts at unassisted transfers. Witnesses reported they were in the process of up dating the care plan, but this was not initiated in a timely manner allowing RV to attempt self transfer on multiple occasions between 4/3/2012 and 4/7/2012 which resulted in falls with injury. The facility failure to ensure a safe environment for RV constitutes abuse and is an Oregon Administrative Rule violation.",3,400,Substantiated,Substantiated,Neglect +AS129877,385144,NF,2/3/2012,Alarms were care planned for RV. Alarm types were changed when found ineffective. On 12/22/2011 RV was found on the floor uninjured; RV's sentry alarm was not in place as care planned. RV's alarm was changed again with RV still sustaining falls even with the alarm in place. On 2/3/2012 RV was found on the floor with a skin tear to the right forearm; the seat belt alarm was turned off. RV's care plan was not always followed. The facility failure resulted in a Oregon Administrative rule violation.,2,0,Not Substantiated,Substantiated, +OR0000832800,385144,NF,6/3/2013,Resident 2 sustained a change of condition at which time Staff 5 failed to follow physician and or facility policy orders to initiate CPR. Other staff intervened and provided CPR and the resident was transferred for further treatment. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000835600,385144,NF,6/13/2013,"Resident 1's care plan identified impaired mobility and use of a gait belt for transfers. Staff 3 failed to use a gait belt on 5/16/2013 while ambulating Resident 1, resident stumbled, was lowered to the floor and sustained a skin tear to the elbow. Evidence is not conclusive having the gait belt would have prevented the skin tear while the resident was lowered to the floor. Staff 3 reported inability to locate a gait belt at the nurses station and failed to go to central supply to look for a belt. Staff failed to follow resident's care plan . Enforcement action was recommended. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000865800,385144,NF,12/4/2013,"Resident 1 was admitted 2/26/2013 following back surgery. Resident was admitted with specific wound care orders including monitoring for redness, swelling, drainage or increased pain at the incision site. Resident's incision showed signs of change beginning 3/8/2013 including an open area, progressed to bloody drainage on 3/11/2013 with signs of slough and vital sign changes beginning 3/12/2013. The resident began to request more pain medication on3/12/2013. The facility failed to follow physician orders regarding wound care or timely notification of the resident's changing condition. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000883100,385144,NF,3/19/2014,"Resident 1 was re-admitted to the facility 2/2014 with multiple diagnoses. Resident was sent to the hospital on 3/16/2014 and a hospital note indicated resident reported rough treatment during toileting and in the dining room. A facility investigation noted resident ability to identify Staff 10. Staff 10 admitted he/she may moved resident rapidly from the bathroom and not informing the resident when moving him/her around in the dining room. Staff 10 was counseled. Staff 10 failed to treat the resident with all due respect, but evidence is insufficient to support abuse. Staffing concerns were identified . Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000892800,385144,NF,4/23/2014,Resident 1 was re-admitted 2/2014 with multiple diagnoses and history of falls. A nursing note of 3/3/2014 indicated the resident slid out of bed. No facility investigation was completed when the resident sustained an un-witnessed event resulting in resident injury. Resident's tab alarm was not place and staff reported resident history of alarm removal. Staff failed to communicate with each other in an adequate manner regarding the resident's removal of alarms placing resident at risk. Resident's care plan was not updated to address resident behaviors and risk for harm. Additionally it was found the facility failed to have adequate staffing. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +AS135247,385144,NF,11/11/2013,"W1 stepped away momentarily, RV attempted a self transfer, fell and sustained ""small"" skin tear to the left elbow. W1 failed to set the tab alarm. Alarms in and of themselves do not prevent all falls. Evidence is inconclusive the alarm would have prevented this fall. W1 received counseling. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +AS148259,385144,NF,8/24/2014,"The complainant reported RV was not receiving scheduled bathing and catheter care. RV corroborated the complaint. W1 reported RV's catheter is to be flushed PRN and RV has declined showers that were offered. Documentation review noted catheter care was provided as planned, but there is a lack of documentation regarding RV's acceptance or refusal of showers. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000973200,385144,NF,5/29/2015,"Resident 106 was admitted May 2015 with multiple diagnoses and physician orders including administering warfarin with monitoring by drawing PT/INR blood for testing weekly. The facility failed to adequately monitor the use of anticoagulants medication resulting in the resident reaching a critical blood high INR and the resident sustaining bleeding with a resulting anemia which required hospitalization. The resident's MAR, TAR and care plan did not direct staff to monitor the resident for signs of adverse effects from the warfarin. There was not system in place to alert nursing to follow-up with labs. Relevant portions of the survey are attached. A federal civil monetary penalty was given. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000994600,385144,NF,8/17/2015,Resident 1 was admitted July 2015 with multiple diagnoses. Resident 1 was sent to the hospital with a change of condition on 8/3/2015 and was re-admitted 8/10/2015 with a PICC line and specific physician orders. The resident's PICC line was found without a cap in place on 11/13/2015. Additionally resident record review found facility failure to document PICC line care; specifically for Resident 4. Resident's 10/10/2015 physician orders to change the needleless connection once a week and observe the line site each shift was not consistently documented in the October TAR. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0001016000,385144,NF,10/15/2015,"Resident 2 was admitted January 2015 with multiple diagnoses. Resident 2's fall care plan dated 2/2/2015 identified multiple interventions. On 9/20/2015 the resident was found on the floor without noted injury. The facility investigation was noted as incomplete. On 10/8/2015 the resident was found on the floor with a forehead injury; the investigation was incomplete. The resident's alarm was in the off position, but the investigation failed to note when the resident was last checked. The resident's care plan was not thoroughly followed. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000668705,385145,NF,2/14/2011,"Resident 3 was admitted on1/18/10 with multiple diagnoses including ESRI, diabetes, CHF, weakness, malnutrition, etc. On 1/25/10 staff requested an order for routine anti-nausea medication; the physician ordered anti-emetic medication. Staff failed to clarify the order. Nursing notes revealed Resident 3 intermittently complained of nausea. The initial fax of 1/25/10 was not clarified until 3/1/10. Resident 3 received the medication intermittently beginning 3/3/10. Relevant portions of the survey are attached. Enforcement action was taken with the facility.",2,0,Not Substantiated,Substantiated, +OR0000679400,385145,NF,3/30/2011,Resident 2 was admitted October 2009 with multiple diagnoses including cognitive impairment and gait instability. A care plan of 2/10/11 indicated assistance with toileting. The plan also instructed staff to transfer using two people and a gait belt. Staff were stay with the resident. Staff 19 had left Resident 2 alone in the bathroom to retrieve a wash cloth. The 3/29/11 fall was the first since 2009. Staff 19 confirmed he/she knew not leave Resident 1 alone. RP2 reported now staff use walkie talkies. Relevant portions of the survey are attached. Enforcement was taken in the form of a directed in-service.,2,0,Not Substantiated,Substantiated, +OR0000679500,385145,NF,3/30/2011,"Resident 1 was admitted 11/16/10 with multiple diagnoses. Resident 1's assessment and care plan revealed pressure reduction intervention including use of a special mattress/wheel chair cushion, weekly skin audits and repositioning. Physical therapy (PT) began a trial use of the AFO on 3/23/11 without sign/symptoms of pain or skin issues. PT wrote a therapy note ""to be applied by PT only at this time."" PT normally removes a device from a resident's room that only therapy will be using or until therapy has in serviced staff to use. On 3/24/11 Staff 3 assumed the boot in Resident 1's room was a replacement for the previously used left foot boot. Staff 3 placed the boot at 11:30 and it remained in place until 8:30 P.M. at which time a blister was found to the top of the foot. A another blister was found to the bottom of the left foot on 3/27/11 and Resident 1 was sent to the ER where a deep vein thrombosis (DVT) was noted. The DVT was not related to the use of the brace. Staff 4 reported he/she was waiting for further instruction from PT. Due to miscommunication between nursing and the therapy department Resident 1 sustained a foot injury. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Substantiated,Substantiated,Neglect +BC120930,385145,NF,7/27/2012,"RV's wallet/money was counted at approximately at 10:30 A.M. on 7/27/2012. RV went out of the facility, returned in approximately 20 minutes and complained the wallet/money was missing. Staff searched in and out of the building, but the wallet remained missing until 8/1/2012; money still missing. The facility contacted the police and provided surveillance camera video. The video shows RP2 in the area were RV had been. While the video indicates RP2 bent over to pick something up, it does not show what RP2 picked up. RP2 denies taking the wallet or money. RP2's employment was terminated. Evidence is insufficient to state exactly who may have taken the wallet and money. The facility failed to provide a safe environment resulting in theft of the resident wallet.",2,0,Substantiated,Substantiated,Financial abuse +BC121103,385145,NF,9/16/2012,"RP2 and witnesses give conflicting statements regarding the incident. RP2 reported bringing RV along the hallway as RP2 was completing his/her duties as assigned by W5. RP2 stated RV was ""screaming and crying""; and RV can be anxious, restless, attempts to stand and is a fall risk. RP2 reported W4 would not be able to help RV if RV fell. W4 reported providing 1:1 assistance to RV at W5's direction and told RP2. W3 reported W4 and RP2 were ""bickering"". W5 reported hearing RV, found RV with RP2 in the hallway and observed W4 ""jump up and start yelling"". W5 also reported RV had begun to calm down and ""watch"" staff in the hallway. Multiple staff failed to perform their duties in a professional manner which subjected RV and other residents within sight/ear shot to staff ""bickering"" and or arguing. This identified failure and failure to honor RV's choice of care is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +BC132671,385145,NF,2/26/2013,"On 2/26/2013 staff found two bruises to RV's side and back. RV was a recent return from the hospital on 2/13/2013 with out observed bruising. RV is not able to give relevant information. Staff CNAs observed bruising prior to 2/26/2013, but assumed bruises had already been reported. The facility failed to ensure prompt assessment and reporting of bruises; injury of unknown origin. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +BC133879,385145,NF,7/11/2013,"RP2 signed as giving RV medication, but did not give the medication; accidently took another resident's medication from the cart; and failed to inform W1 of the error. RV did receive the correct medication 1 1/2 hours later. RV was at risk for minimal harm when waiting for the pain medication. The facility is responsible for their staff, but there was no failure to maintain a safe medication system identified in this report. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC146714,385145,NF,4/4/2014,"RP2 was assisting RV to eat and drink when RV's drink went on both RV and RP2. RP2 acknowledged laughing, attempting diversion and was trying to hold RV's hands while wheeling RV out of the dining room so RV would not sustain injury. RV grabs and moves about. RP2 did fail to step away from the situation. Another staff intervened and told RP2 to leave RV alone. RP2 failed to use good judgment. The facility does teach disengagement and re-approach. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC148144,385145,NF,8/8/2014,"RV reported inappropriate touch by RP2. multiple witnesses report RV has a history of being aggressive with staff and forming complaints against staff RV does not like. Staff provide RV care in pairs. Staff have attempted other interventions, but RV refuses. Staff continue to problem solve RV's behaviors. RP2 and W8 deny inappropriate touch while providing peri care to RV. RV's care plan was changed to only female care givers providing care; ok for male care giver as second observing care giver. The facility failed to promptly report RV's allegations. A Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000908600,385145,NF,7/15/2014,Resident 1 was admitted 4/26/2014 with COPD and pituitary excision on chronic steroids. Resident's medication record indicated resident's prednisone used for COPD was tapered off per physician orders without notifying resident family; resident's daughter was primary contact for health care. The resident sustained a change of condition on 6/22/2014 resulting in a transfer to the hospital. The resident was re-admitted with medication and the MAR listed the pituitary disorder as the reason for the predisone. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +BC151367,385145,NF,5/8/2015,"From May 3, 2015 up to and including May 20, 2015 RP2 signed as giving narcotic PRN medication to RV during morning hours. RV denied receiving the medication, reported only asking for and receiving narcotic medication in the evening. Review of RV's medication record indicated RV received the narcotic medication in the evening except on the seven days RP2 signed as giving RV the medication in the morning. RP2 signed as giving RV medication at 10:00 A.M. on May 20, 2015, but RV had left the building at 9:30 A.M. Per a police reported dated 5/22/2015 RP2 reported giving the medication to RV and RP2 was asked to complete a drug test, but failed to show up for the test. During the June 9, 2015 interview RP2 admitted taking RV's medication, as well as, taking narcotics from different facility residents beginning January 20, 2015. RP's theft of RV and other resident (s) narcotic medication constitutes abuse. The facility failure to provide a secure environment resulting in repeated theft of RV's and other resident(s) medication constitutes facility abuse. Oregon Administrative Rule violations occurred.",3,500,Substantiated,Substantiated,Financial abuse +ES105757A,385147,NF,11/15/2010,"RV1 was admitted on 11/15/10 with a non-surgical wound. RV1's skin wound was assessed, but no treatment or care plan was revealed between 11/15/10 and 11/25/10. The wound was treated beginning 11/26/10 and became open on 11/29/10.",2,0,Substantiated,Substantiated,Neglect +OR0000754300,385147,NF,4/5/2012,Resident 1 was admitted 3/20/2012 with multiple diagnoses including a fractured right hip. Resident 1 fell 11 times from 3/21/2012 through 4/4/2012 resulting in a fractured left hip. Staff gave conflicting information regarding whether or not Resident 1's alarm was sounding at the time of the 4/4/2012 fall. The facility failed to thoroughly investigate the fall event. Additionally surveyors found on 3/31/2012 at 1:10 A.M. Resident 1 was assisted to the toilet and left alone while staff retired supplies. Resident fell without injury at this time. Resident personal alarm was not in place at the time of the 3/31/2012 fall. Resident care plan was not up dated at time of the falls. Relevant portions of the survey are attached. Enforcement was proposed. The facility failure was an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +ES146173,385147,NF,2/20/2014,"RP2 failed to assist RV1 or RV2 in a timely manner with incontinence care. RV1 reported asking RP2 for a urinal, did not receive the urinal, ""was told to pee in my bed and laid in the pee"". RV1 reported feeling neglected by RP2. RV2 reported incontinence care is delayed. W1 and W2 reported coming on shift after RP2 on multiple occasion to find residents with dried feces on their body and urine soaked. W3, administrative staff, knew of RP2's poor performance and resident complaints from July 2013 through January 2014 and provided warning, but kept RP2 on night shift which has less supervision. W4, administrative staff, directed the investigator to speak with W3, but W4 would also be aware of RP2's poor performance and resident complaints. RP2 failed to honor resident requests for care; and failed to provide incontinence care resulting in neglect of care and great loss of resident dignity which constitutes abuse. The facility failed to ensure residents received timely incontinence care resulting in continued neglect of resident care and great loss of resident dignity which constitutes abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +ES146840,385147,NF,4/15/2014,"RP2 transferred RV without reading RV's care plan. RP2 failed to face RV when speaking to RV; RV did not hear RP2. RV reported RP2 transferred RV incorrectly by picking up RV's legs and swinging them into bed causing RV discomfort. RP2 reported it was not in RV's care plan regarding RV's prior injury and RP2 did not realize RP2 needed to face RV when speaking. RP2 is still learning and although RV's care plan speaks to limited mobility, evidence presented does not give specific parameters regarding RV's injury and transfer. RP2 reported trying to be gentile. RP2 received counseling and further training. The facility failed to ensure thorough training for RP2 resulting in RV's discomfort. Oregon Administrative rule violation occurred.",2,,Substantiated,Substantiated,Neglect +ES148179,385147,NF,4/1/2014,The complainant and RV voiced multiple concerns regarding RV's care during RV's stay in the facility. The major concern was RV not receiving RV's blood pressure medication. Witness interview and documentation review indicate RV did not receive his/her blood pressure medication on 4/18/2014 due to the medication not being available. There is no documentation to explain why the medication was not available. There were two other times RV refused medication. Resident's blood pressure remained at RV's normal levels. The facility failed to have adequate medication systems in place to ensure medication is available and dispensed. RV was at risk for harm. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000953200,385147,NF,3/9/2015,"Resident 1 was admitted September 2014 with diagnoses including a fractures and osteoporosis. on 10/8/2014 staff found the resident on the bathroom floor with bleeding to the back of his/her head. Nursing notes indicate the resident's family and Staff 2 were notified, but there was no documentation the physician was notified. The resident's October 2014 care plan indicated resident fall risk and interventions, but there was no updated care plan following the 10/8/2014 fall. Staff failed to provide adequate follow-up to the resident's injury fall when the resident showed increased confusion, increased bruising and pain to the left upper arm. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +GP105574,385148,NF,10/27/2010,RP2 gave RV another resident's medication after speaking to RV using another resident's name. RP2 failed to follow the 5 rights of passing medication. RP2 immediately reported the event to the director of nurses. RV's physician and family were notified and RV was monitored. RV did not sustain adverse effects. RP2 was counseled for his/her error.,2,0,Not Substantiated,Substantiated, +OR0000702202,385148,NF,7/25/2011,"Staff reported residents are treated like family and staff frequently refer to a resident as honey, dear or a pet name. If a resident wishes staff honor their request to be addressed as something else. Staff 1,4, 5, 6 and 9 reported they would not leave a resident pants half down at nap time as it would present a safety hazard. The incident presented as a one time event. Staff 1 provided immediate in-service for staff to prevent a similar future event.",2,0,Not Substantiated,Substantiated, +GP120819,385148,NF,8/2/2012,"RP2 obtained medication from the facility E-Box for RV2(order had been discontinued), RV3, RV4, RV5 and RV6 without physician orders. RP2 also obtained medication from the E-Box for RV1; orders were found later. Evidence was insufficient for negative resident outcome. RP2's employment was terminated and the appropriate agencies were immediately notified. The facility worked closely with the pharmacy during an audit that discovered the medication discrepancies. The facility up dated the policy and procedure regarding use of the E-Box and provided appropriate staff in-service.",2,0,Not Substantiated,Substantiated, +GP121378,385148,NF,10/23/2012,"While re-injury occurred, evidence is insufficient to state that RP2 caused the injury. RV complained of pain off and on after RP2's assistance and RV received ice and pain medication with good effect while continuing physical therapy. The facility did fail to immediately notify RV's physician when there was change in RV's complaints of pain. An Oregon Administrative Rule violation occurred.",2,0,Inconclusive,Substantiated, +GP132399,385148,NF,2/13/2013,"RV was placed in Hospice service since January 3, 2013. Staff were assisting RV using a gait belt which caused bruising to RV's chest. RV's care plan did not contain reference to use of a gait belt or a Hoyer lift. W2 reported the gait belt was not utilized in the ""normal manner"". Hospice ordered a lift to be used. RV's care plan failed to show a thorough assessment and care plan for use of a gait belt outside the normal manner. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +GP132295,385148,NF,2/1/2013,"The complainant reported a cream for another resident was placed on RV's back. Witnesses reported a barrier cream was applied and removed when the error was discovered. Witnesses reported the cream should not cause burning, tingling, etc.; it is only to protect the skin. W4 and W5 gave differing statements as to why the cream was applied. The resident did not sustain notable negative effects. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +GP116088A,385148,NF,1/5/2011,Staff delivered an extra dose of antibiotic after the physician orders were changed. The facility failed to write the dosage change in the MAR. The resident was at risk for harm. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +GP134253,385148,NF,8/29/2013,"Based on further evidence RV did not receive additional doses of medication, but documentation in fax and record were inaccurately reflecting medication RV received. Staff faxed and or were in contact with RV's primary care physician (PCP) on numerous occasions, but staff did not inform RV's PCP accurately of medication dosage RV received. While RV did sustain a decline in condition evidence does not conclusively link the decline to medication RV received. The facility failed to maintain an adequate medication system placing RV at risk for harm. Oregon Administrative Rule violations occurred.",2,400,Not Substantiated,Substantiated, +GP133587,385148,NF,6/24/2013,"The complainant and RV reported RV only receiving half dose of ordered medication. Staff did initially administer half a dose of medication, monitored RV for pain and contacted RV's physician regarding RV's pain. RV did receive increased medication and better pain relief. Staff received further in-service regarding medication administration. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000866200,385148,NF,12/10/2013,Resident 1 was admitted 8/12/2013 with diagnoses including bipolar disorder and physician orders for Lithium 300 mf once in the morning and evening. The resident's Lithium was not given as ordered on 8/15/2013. The resident's Lithium dosage was changed on 8/19/2013 at 8:15 A.M. and transcribed to begin 8/20/2013. the resident did not receive ordered Lithium 8/19/2013 A.M. and only half of the dose in the evening on 8/19/2013.res 1 was at risk for harm. Relevant portions of the survey are attached. Enforcement action was requested. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +GP146148,385148,NF,2/21/2014,The complainant reported a lack of toenail care for RV. RV was unable to give relevant information. W1 reported RV is not able to walk due to length of toe nails and the toe nail issue is causing problems with circulation to RV's feet. RV's nursing notes indicate RV has problems with leg edema and infection under the skin on RV's legs. Staff were in contact with RV's physician on 2/4/2014 regarding RV's complaints of pain and both legs/feet being bright red. RV's toe nail assessment of 2/24/2014 revealed thickened nails of varied length with broken and crumbly nails. RV refused nurse attempts to trim the nails. A podiatrist appointment was scheduled for 3/31/2-14. The facility failed to provide adequate toe nail care for an extended period of time. A reasonable person would be embarrassed to have his/her toe nails looking like RV's which constitutes a loss of dignity and neglect of care. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +GP132076,385148,NF,12/29/2012,"Staff failed to ensure RV wore the prescribed neck brace. RV was sent to the hospital by an unknown staff without his/her neck brace. Hospital staff were not informed of RV's need to wear a neck brace. RV was not injured, but at significant risk for injury. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +GP151119,385148,NF,4/27/2015,"The complainant voiced concerns as indicated in the attached report. RV voiced some concerns, but deferred to spouse. RV feels staff rush and do not always use two staff for RV, but staff try and move RV's tubing when moving RV. Two staff repositioned RV on 4/26/2015 with both staff stating the feeding tube ""just popped out"". Although the bulb on the feeding catheter was inflated evidence is insufficient as to whether the blub was inflated as ordered or had deflated enough to slip out. Evidence fails to support staff dislodged RV's feeding tube. RV's dislodgement of the tube required an ER visit. Oregon Administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +OR0001064200,385148,NF,2/16/2016,"The facility failed to meet professional standards for medication administration, as well as, failure to administer medication as ordered resulting in risk for and actual adverse reactions for Resident 237. RP2 dissolved oral medication in water and gave the dissolved medication through Resident 237's PICC line instead of through resident's gastric tube. The resident sustained a change in condition, transferred to the ER and hospitalized for over 24 hours. The facility failed to ensure all staff responsible for giving medication through a resident's PICC line were properly trained and capable of performing the task. The facility failure constitutes neglect and abuse. RP2 by virtue of professional training would have known dissolving oral medication and placing it in a central IV (PICC) line placed the resident at extreme risk for harm. RP2 had already made an earlier medication error. RP2 failed to seek help and/or direction from qualified licensed staff regarding resident's medication administration and the proper delivery system to be utilized prior to administering Resident 237's medication. RP2's actions caused Resident 237 chest tightness, nausea and sweating palms resulting in Resident 237's change of condition and hospitalization. RP2's actions resulted in a Resident 237's negative outcome which constitutes neglect and abuse. Relevant pages of the survey are attached. Facility enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +GP118093,385149,NF,8/4/2011,RP2 used RV's truck for a day and returned RV's truck with gas in the tank. RP2 reported receiving a check from RV in the amount of $200.00 for services he/she provided before and during RV's facility stay. RV reported she/he gave RP2 the check as a gift; RP2 was having financial problems. RP2 acknowledged knowing it was wrong and against facility policy to receive the check from RV. The facility terminated RP2's employment.,2,0,Not Substantiated,Substantiated,Financial abuse +OR0000750000,385149,NF,3/16/2012,"Resident 2 was admitted July 2011 with diagnoses including a fall and a right hip fracture. Resident's admission form indicated fall risk and the staff pocket care plan of 8/4/2011 indicated moderate assist when using a walker. The care plan of 8/10/2011 revealed interventions of a bed alarm. The 8/19/2011 pocket care plan did not include the use of a Tab alarm. Resident 2 fell on 8/28/2011 and was found holding his/her Tab alarm. The 8/29/2011 investigation recommended use of a pressure alarm. The 8/31/2011 pocket care plan did not include other safety devices, i.e.. Alarms. Resident 2 moved to another unit on 10/4/2011 and the 10/7/2011 pocket care plan failed to direct staff to stay with the resident in the bathroom, but included use of the alarms. Resident 2 fell on 10/14/2011 while left alone in the bathroom and sustained a head laceration. The facility failed to provide to ensure an adequate care plan for Resident 2's safety. This failure supports a Oregon Administrative rule violation.",2,0,Inconclusive,Substantiated, +OR0000768700,385149,NF,6/22/2012,"Resident 1 was admitted December 20120 with multiple diagnoses including spina bifida with paraplegia, bilateral knee amputations, scoliosis, chronic pain, and more. Resident was care planned for safety and mobility including bilateral side rails use. On 1/4/2011 at 11:45 P.M. Resident 1 fell out of bed when one side rail was not up as care planned. Resident 1 sustained injury to his/her face and wrist; transferred to the ER for evaluation. Staff had observed the resident sleeping prior to the fall and believed the resident may have seizure. Multiple staff observed the bed rail down and or missing from the resident's bed prior to the fall. The facility failed to ensure Resident 1's care plan was followed resulting in a preventable injury. Relevant portions of the survey are attached. A civil penalty was proposed. This facility failure is a Oregon Adminstrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +OR0000811603,385149,NF,2/13/2013,"Resident 1 was admitted July 2010 and re-admitted January 2013 with multiple diagnoses. Resident 1 did not receive appropriate oral care on 2/12/13, but no other episodes of poor oral care were reported. This event was an isolated event. An Oregon Administrative Rule violation occurred.",1,0,Not Substantiated,Substantiated, +GP159837,385149,NF,1/7/2015,"Witnesses give conflicting information regarding RV's medication for pain. The majority of witnesses deny RV was over medicated. RV did have a UTI which could cause RV's confusion. RV was offered food and fluid, but was slow to start consuming nutrition until RV's family arrived. RV's bowel protocol was not adequately followed; only received MOM the third day (12/21/2014) of no bowel movement and no other treatment per protocol was given. RV did have bowel movements after 12/24/14, but RV did fail to have a bowel movement for 6 days. Staff failed to notify the DNS or RV's physician of RV's lack of a bowel movement for 6 days. The facility failure to adequately address RV's bowel needs constitutes neglect of care and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000966700,385149,NF,4/30/2015,"Resident 40 was admitted 2015 with diagnoses including chronic renal failure. On 4/7/2015 the resident sustained an witnessed injury fall. Record review found no documentation of a comprehensive investigation to rule out possible abuse/neglect. The resident sustained another fall on 4/21/2015 without a timely investigation. Resident's CAA dated 2/26/2015 indicated the resident was a risk for falls. Resident's comprehensive care plan updated 4/24/2105 did not identify a fall risk, there were no measureable goals regarding falls and no documented staff interventions to reduce the potential of falls. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000955801,385149,NF,3/18/2015,"Resident 23 was re-admitted 2/25/2015 with multiple diagnoses. Resident's 3/3/2015 MDS assessed the resident as alert, oriented and able to make own decisions. The resident's initial care plan addressed resident need including limited assistance to eat and risk for dehydration due to recent UTI and swallowing problems. There was no comprehensive care plan to address the resident's potential risk for dehydration with interventions and goals to ensure sufficient hydration. Staff 2 acknowledged the resident's care plan was incomplete. Staff 19 reported encouraging resident to take fluids as resident's urine turned dark. Staff notified the resident's physician of the resident's change in condition. Oregon Administrative Rule violation occurred.",0,,Not Substantiated,Substantiated, +OR0000973802,385149,NF,6/3/2015,"Resident 3 was admitted 3/28/2015 with multiple diagnoses. Documentation review and witness interview noted Resident 3 received on going monitoring and assessment with change of condition. Resident 5 was admitted 4/3/2015 with diagnosis including a hip fracture. The complainant reported the fracture was reported, but nothing was done. Record review and witness interview determined the resident was admitted following a surgical procedure with bruising to both hips and a surgical incision site. The resident received daily monitoring, assessment and the physician was notified of change in condition with treatment orders initiated and followed. Resident 6 was admitted January 2015 with multiple diagnoses. Record review and witness interview indicate the resident exhibit behaviors including agitation, sliding out of the wheel chair, removing alarms, etc. Multiple interventions were placed for resident safety. Between May 2015 and July , 2015 there were no noted falls. The resident was discharged on 7/9/2015. Resident 6 received Coumadin placing the resident at risk for bruising. The resident behaviors of thrashing in bed and placing his/her face on the wheel chair arm rest could have caused bruising. The resident care plan was adjusted for safety during the resident's stay. During the investigation an additional resident safety hazard was discovered and cited. Relevant portions of the survey are attached. Enforcement actions was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +GP152411,385149,NF,8/10/2015,Per witness interview and record review it identified facility failure to adequately care plan and provide toe nail care per physician orders. RV's toe nails curled over and under with W1 reporting RV complained of discomfort. The neglect of RV's toe nails and the resulting discomfort constitutes abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0000989600,385149,NF,8/6/2015,Resident 1 was admitted February 2014 with diagnoses including failure to thrive. Documentation review and interview indicate resident's CPAP was not always placed. Resident' oxygen saturations were not always obtained and or documented. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Inconclusive,Substantiated, +OR0000989601,385149,NF,8/6/2015,Resident 1 was admitted February 2014 with diagnoses including failure to thrive. Record review and interview indicate staff failure to make timely dental appointments for the resident at physician order. The resident's gums were bleeding and teeth were loose prior to the physician orders of 8/6/2014 to obtain a dental appointment. There was a dental appointment for January 2015 per a social services note. The resident denied any pain. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Inconclusive,Substantiated, +OR0000997800,385149,NF,8/28/2015,"Resident 2 was admitted April 2015 for a fractured right fibula. Record review and interview indicate the resident did not receive all ordered doses of Coumadin, Nya statin ointment, Carvedilol and insufficient documentation regarding effectiveness of Tramadol. The resident's oxygen saturations were not checked as ordered. The resident was at risk for harm. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000997801,385149,NF,8/28/2015,Resident 2 was admitted April 2015 for a fractured right fibula. Record review and interview indicate the resident's physician orders regarding monitoring oxygen saturation levels were not always followed. Resident's CPAP was not always placed as ordered. The resident was at risk for harm. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +BH105643,385150,NF,10/27/2010,Resident #1 was unable to locate her/his blue sweater. Facility failed to provide a secure environment resulting in theft of an item of Resident #1's clothing. Please refer to attached complaint report.,2,0,Not Substantiated,Substantiated,Financial abuse +OR0000673200,385150,NF,3/2/2011,Resident #1's 1/20/2011 care plan specified Resident #1 required two-person extensive assistance for transfers. On 2/24/2011 staff #4 attempted to transfer Resident #1 from a commode back to bed without waiting for a second CNA; Resident #1's legs were too weak and gave out. Staff #2 said Resident #1 was assessed for injury and there were no injuries. Relevant portions of the survey report attached.,2,0,Not Substantiated,Substantiated, +OR0000692000,385150,NF,6/2/2011,"Based on documentation and interview evidence indicated facility failed to provide adequate care and services to prevent Resident #1's fall on May 30, 2011. Relevant portions of the complaint report are attached.",2,0,Not Substantiated,Substantiated, +OR0000692001,385150,NF,6/2/2011,On 5/31/2011 RP2 (CNA) was told by staff #5 (CMA) that Resident #1 was on the floor. RP2 told staff #5 that Resident #1 had fallen several times that day and the floor was the safest place for Resident #1. RP2 continued to bathe another resident. Resident #1 remained on the floor for approximately 45 minutes before nursing staff assessed Resident #1. It was determined Resident #1 had not sustained any injury. Relevant portions of the complaint report are attached.,2,0,Not Substantiated,Substantiated, +BH117060,385150,NF,5/14/2011,Evidence and interviews indicated facility failure to follow Resident #1's care plan and implement behavior interventions when an altercation occurred between Resident #1 and Resident #2 on 5/14/2011. Witness #3 said neither Resident #1 nor Resident #2 sustained injuries as a result of the 5/14/2011 altercation.,2,0,Not Substantiated,Substantiated, +BH118621,385150,NF,11/30/2011,Resident #1 had an order for PRN (as needed) pain medication every four hours. On 11/30/2011 sometime between 10:15 and 11 pm Resident #1 complained of pain and requested medication. RP2 did not give Resident #1 medication until 11:45 pm. RP2 told W2 and W3 that Resident #1 could not just scream and get what she/he wanted.,2,0,Not Substantiated,Substantiated,Neglect +BH134121,385150,NF,8/1/2013,Evidence and interviews indicated RP2 failed to treat Resident #1 with dignity and respect while assisting Resident #1 with her/his care on or about 08/01/2013.,2,,Not Substantiated,Substantiated, +BH145950,385150,NF,11/24/2013,Evidence and interviews indicated facility failure to assure Resident #1's safety related to an incident on 11/24/2013 where Resident #1 left a locked area of the facility where the alarm was found to be off at the time of her/his exiting. Resident #1 was found walking down a street. Resident #1 was assessed by a licensed nurse after returning to the facility and found to be without injury.,2,,Not Substantiated,Substantiated, +OR0000891100,385150,NF,4/15/2014,"Evidence and interviews indicated facility failure to obtain timely pressure ulcer treatment for Resident #4. Progress notes for Resident #4 dated 5/17/2014 indicated she/he was found to have a pressure ulcer on the right buttock. A 5/22/2014 treatment order indicated Resident #4_x001A_s pressure ulcer treatment was done as ordered five days after the pressure ulcer was identified. The facility failure to provide timely pressure ulcer treatment for Resident #4 placed her/him at risk for complications related to the pressure ulcer. Evidence and interviews indicated facility failure to ensure medical records were accurate and completed for Resident #1, Resident #2, Resident #3 and Resident #4. This failure placed residents at risk for a lack of coordinated care. Relevant portions of the complaint report investigation are attached.",2,1200,Not Substantiated,Substantiated, +OR0000891101,385150,NF,4/15/2014,Evidence and interviews indicated facility failure to complete comprehensive neurological checks for Resident #1 and Resident #3 who sustained falls. Evidence and interviews indicated facility failure to complete orthostatic blood pressures for Resident #1 for three days after her/his 3/29/2014 fall. Evidence and interviews indicated facility failure to update Resident #1's care plan regarding fall interventions and ensure Resident #1's safety; placing Resident #1 at risk for injuries from falls. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +BH150217,385150,NF,2/11/2015,Evidence and interviews indicated facility failure to assure Resident #1's right to receive care and services or decline care and services when RP2 (CNA) refused to stop providing Resident #1 with care on or about 2/9/2015. Facility failure to assure Resident #1's rights resulted in Resident #1 becoming upset.,2,,Not Substantiated,Substantiated, +RB117049,385151,NF,5/20/2011,"RV reported no prior problems with RP2 until 5/20/11 when RP2 told RV1 ""you are too hard to transfer, use the bed pan"" and then stated to RV1 to ""use the bed pan or go in the bed."" W3 reported RP2 was hostile with residents and would raise his/her voice. RV2 reported RP2 told him/her ""you already have two blankets"" and then went and got one. RV2 reported RP2 hung his/her clothes in the closet after RV2 told RP2 she/he wanted them kept out. RP2 gave similar statements as RV1 and RV2, but denied leaving RV1 unattended; may have told RV2 ""no"" when requesting an extra blanket, but was teasing. RP2 failed to treat RVs with all due respect by not promptly addressing their personal choice in the care that was provided..",2,0,Not Substantiated,Substantiated, +OR0000694100,385151,NF,6/16/2011,"Resident 1 was admitted 1/13/2011 with diagnoses including dementia and a history of falls. Resident 1's in room care plan of 4/14/2011 indicated use of alarms, crash mats, etc. On 5/14/2011 Resident 1 was found on his/her room floor near his/her wheel chair; no alarm on the wheel chair. While alarms in and of themselves do not prevent all falls, Resident 1's care plan was not consistently followed. Staff report conflicting information regarding the care plan and some confusion as to Resident 1's care plan due to ""two orders in one sentence."" The facility failed to report this injury event to SPD in a timely manner. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +RS129455A,385151,NF,2/27/2012,"RV has a history of left upper arm decrease ability to feel pain, has a history of skin infection and indication of skin at risk (fragile skin). W3 reported alerting staff to arm injury, staff dressed the wound and staff failed to continue to change the dressing in a timely manner. Staff failed to record the arm injury or dressing of the wound. RV was at risk for skin infection. The facility failure resulted in a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +RS129455B,385151,NF,2/27/2012,"W1 reported several issues regarding RV's care were raised including poor call light response, being left in soiled garments for hours and bowel protocol not being followed resulting in RV with some constipation. RV did not recall if he/she told staff he/she was not feeling well. W3 reported talking with staff, RV received an enema and RV felt better. RV reported catheter leaked and clothing/bed linens were wet. W5 reported a ""glitch"" in the system and staff were not alerted to regarding RV's bowel protocol. Proper bowel care was given inconsistently resulting in transitory discomfort to RV. The facility failure is a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +RB121614,385151,NF,11/9/2012,"RP2 reported checking RV prior to taking RV to the dining room and RV was dry. RP2 denied he/she would leave RV soiled. W2 and W3 found RV wet with dried feces on pants and shoes after returning RV from the dining room, as well as, finding soiled bed linens and recliner pad. Witnesses reported asking RP2 to change RV before RP2 went on break and RP2 said ""no"". RP2 reported changing RV after RP2 returned from his/her lunch break. RP2 failed to provide prompt incontinence care to RV and left RV wet and soiled. This failure constitutes abuse. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated,Neglect +OR0000792600,385151,NF,11/5/2012,"Resident 1 was admitted 10/8/2012 with multiple diagnoses. Resident's care plan addressed fall risk with interventions including frequent safety checks, pressure alarm and one person assistance with transfers using a gait belt and walker. On 10/9/2012 the resident attempted a self transfer and was found on the floor with injury. The facility must operate and provide services to ensure the resident remains free of accident hazards, receive supervision and assistance devices to prevent accidents. Relevant portions of the survey are attached. Enforcement action was recommended. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000805600,385151,NF,1/22/2013,"Resident 1 was admitted July 2012 with multiple diagnoses. Resident's in room care plan dated 1/4/2013 indicated a two person transfer assistance with gait belt due to resident fall risk. On 1/20/2013 at 10:50 A.M. a licensed nurse was called to the resident' room, the resident was on the floor, Staff 7 reported the resident's legs gave out during transfer and the resident was lowered to the floor. Staff 7 reported attempting to find assistance with the transfer, but could not find help and the resident (who is alert/oriented) insisted Staff 7 transfer him/her. Staff reported the resident rarely got out of bed and complained of leg pain prior to the this event. Staff 2 reported the leg identified hip fracture may have occurred prior to the incident. All staff received further in-service on following care plans. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +RB132452,385151,NF,2/19/2013,"W2 denies being rough with RV. RV's care plan dated 1/21/2013 indicated staff to accompany RV' spouse in the building, monitor visits and separate the couple if spouse became abusive. On 2/19/2013 staff offered RV and spouse assistance in removing RV's jacket with spouse becoming rough as spouse ""jerked"" RV's arm back and forth. Staff failed to provide adequate assistance to RV and RV's spouse which placed RV at risk for harm. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +RB132709,385151,NF,3/18/2013,"The facility failed to ensure RV's PRN pain medication prescription and or sufficient quantity of pain medication was available for RV when RV requested pain medication at 8:00 A.M. on March 18, 2013. The facility faxed the physician on 3/18/2013 at 8:00 A.M. when discovering insufficient quantity and or lack of a valid prescription for more PRN medication. RV received one tablet of pain medication at 8:00 A.M. on 3/18/2013 when RV usually received two tablets every four hours for pain following recent surgery. Staff failed to promptly follow-up when the physician had not responded to the request in a timely manner. The physician responded at 3:20 P.M., but staff waited until 6:00 P.M. to obtain PRN medication from the emergency box and give medication to RV. RV reported laying in agony, becoming very upset and unable to eat either lunch or dinner. The facility's inaction to ensure RV received pain medication in a timely manner resulting in RV's sustained high level of pain constitutes abuse and an Oregon Administrative Rule violation.",3,200,Substantiated,Substantiated,Neglect +RB147104,385151,NF,5/12/2014,On 5/12/2014 RV1 and RV2 were passing in the hallway when their wheel chairs connected. RV1 slapped RV2; no injury occurred. Neither RV recalls the event. RV1's 11/1/2013 care plan identifies risk for injury for self and others secondary to behaviors. RV1 is to have constant supervision and intervention. RV2's 1/21/2014 care plan identified behaviors and interventions. The facility failed to adequately carry out RV1 and RV2's care plan for preventing physical altercation and potential for harm. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +RB147168,385151,NF,5/21/2014,Witness and RV reported RV1 struck RV2 with a fork and then his/her bag. RV2 does not recall the events. RV1's care plan dated 5/4/2014 indicate risk to RV1 and others. RV2's care plan indicated behaviors. Staff failed to provide adequate monitoring to protect RV2 from RV1's attack. RV2 was not injured. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000937201,385151,NF,12/8/2014,"Resident 1 was admitted October 2014 with diagnoses including end stage liver disease. Staff failed to notify W1 when the resident fell per W1. W1 was notified of the resident fall per staff and documentation, but was not notified when the resident's condition changes. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000937204,385151,NF,12/8/2014,"Resident 12 was admitted October 2014 with diagnoses including end stage liver disease. The resident was admitted with comfort care physician orders. Resident medication was adjusted and or discontinued on 11/2/9/2014. Staff 24 inadvertently gave the resident the wrong dose of Ativan. The card of Ativan was not updated or labeled contributing to the error. The resident was sleeping, but arousable. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000948700,385151,NF,2/11/2015,Resident 3 was admitted January 2015 with a fractured hip. On 2/5/2015 the resident was found on the floor in front of his/her wheel chair after staff left the resident in the wheel chair when the resident declined to lay down. There were no additional interventions identified to address resident refusal to lay down. The resident was not noted to be agitated which would have warranted monitoring at the nurses station. Relevant porti9ons of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +RS151765,385151,NF,6/25/2015,"RV denies any knowledge of being out of pain medication and has not suffered pain from not having his/her medication. W1, 2 and 3 reported normally stickers are pulled from the medication card, placed on a form and faxed to the pharmacy for refill when the supply is down to 7 days; W3 reported when 20 pills are left. RV took PRN medication at 5/28/2015. W4 reported the facility emergency supply was out of RV's particular medication and the pharmacy took a lot of time to process and deliver the medication. There was a departmental note dated 5/16/2015 regarding RV's medication , the E Box medication pulled , 5/17/2015 still of facility medication and the pharmacy was contacted. RV did receive non-narcotic pain medication, but did not have the PRN narcotic medication available if needed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000994200,385151,NF,8/14/2015,"Resident 1 was admitted in 2013 with multiple diagnoses. Resident care plan indicated a one person slide board or Hoyer transfer. On 6/29/2015 Staff 6 assisted the resident with a slide board transfer, the board began to slip, resident lost footing and requested to be lowered to the floor. The resident reported having a new cut on 6/28/2015 and hurt his her knee and ankle. Resident 1 reported he/;she was fine after the fall on 6/29/15, but developed pain later. X-rays of 6/30/2015 revealed osteoporosis and two fractures. Evidence is insufficient to ascertain when the fractures occurred. Resident 1 reported a new graduate C.N.A. assisted with the transfer and failed to listen to the resident. The resident was unable to provide a name or description. Relevant survey pages are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +OR0000994500,385151,NF,8/14/2015,"Resident 2 was admitted 2014 with multiple diagnoses. The resident 8/9/2015 progress note indicated fall risk, dementia and impulsivity. The resident would self transfer and staff were to check the resident often. Staff 47 observed the resident in the dining room around 7:00 P.M. and a student took the resident on a walk to another unit and then informed Staff 44 the resident was left by the front door. The resident was let out of the door and rolled down the hill, fell out of the wheel chair and sustained injury. The facility failed to thoroughly investigate and document when the resident was last seen. Relevant survey pages are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0001014800,385151,NF,10/13/2015,"Resident 2 was admitted 2014 with multiple diagnoses. Resident's care plan dated 8/9/2015 indicated fall risk. Resident attempted self transfer and staff were to check the resident frequently. On 8/14/2015 the resident went out the facility gate, rolled down the hill and fell out of the wheel chair. The resident sustained abrasions. The facility investigation did not address the circumstances regarding the resident leaving the building. Resident 3 was admitted 9/12/2015 with multiple diagnoses and noted fall risk. The resident fell on 9/24/2015 and the facility investigation did not address when the resident was last seen or what the resident was doing prior to this fall. The resident sustained further falls. Resident 3 sustained injury including a large skin tear on 10/11/2015. the facility failed to thoroughly assess, investigate and care plan for resident falls. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0001014802,385151,NF,10/13/2015,"Record review and interview indicate Resident 3, 4 and 5 were at risk for complications from catheter use due to facility failure to obtain complete nursing; and catheter physician orders, as well as, document information regarding catheter changes. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +RS153904A,385151,NF,12/1/2015,"Per interview and record review RV did not receive timely pain medication and or the dose requested. Resident PRN medication was changed to scheduled medication three times per day, with a dose being available to be given between 9 and 11 P.M. The resident also has a PRN available. The resident and family papered pleased with the medication changes. Oregon Administrative rule violation occurred.",2,,Not Substantiated,Substantiated, +RS153904B,385151,NF,12/1/2015,assisting with brief changes 2 to 3 times per shift. The bowel/bladder log noted staff only documenting once per shift instead of each instance of resident assistance. The facility failed to provide timely incontinence care at least once. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000678500,385152,NF,3/24/2011,Evidence and interviews indicated facility failure to follow physician's orders regarding a laboratory test (PT/INR) for Resident #1. Resident #1 was hospitalized with a gastrointestinal bleed. Federal civil penalty recommended; relevant portions of the survey report are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000717500,385152,NF,9/27/2011,Evidence and interviews indicated the facility failed to ensure standards and practices were followed related to aspiration precautions for Resident #1. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000717501,385152,NF,9/27/2011,Evidence and interviews indicated facility failure to ensure the standards and practic related to obtaining physician's orders for the use of compression stocking and oxygen administration for Resident #1. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000731800,385152,NF,12/1/2011,"On 11/3/2011 at 7:00 am Resident #1's CBG was 103, physician's orders indicated insulin was not needed for this CBG result. Staff #2 (licensed nurse) erroneously administered 50 units of Humalog (fast-acting regular insulin) to Resident #1. Resident #1 became hypoglycemic with a CBG below 70 and she/he was hospitalized. Federal penalty recommended; relevant portions of the survey complaint report are attached.",3,0,Not Substantiated,Substantiated,Neglect +OR0000776200,385152,NF,8/2/2012,Evidence and interviews indicated facility failure to provide Resident #2 adequate wound care and services. Relevant portions of the survey complaint report are attached.,3,250,Not Substantiated,Substantiated, +OR0000777400,385152,NF,8/9/2012,Evidence and intereviews indicated facility failure to provide Resident #1 adequate care and services related to skin breakdown. Relevant portions of the survey complaint report are attached.,3,250,Substantiated,Substantiated, +OR0000816200,385152,NF,3/6/2013,Evidence and interviews indicated facility failure to develop and implement a temporary care plan for Resident #1 who was admitted to the facility on 01/25/2013. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +ES133036,385152,NF,4/19/2013,Evidence and interviews indicated facility failure to ensure RP2 (CNA) provided Resident #1 care and services according to her/his care plan.,2,0,Not Substantiated,Substantiated, +ES134279,385152,NF,8/27/2013,RP2 (licensed nurse) documented administering medications to multiple residents that never requested or received medications and instead diverted medications to her/himself.,3,,Not Substantiated,Substantiated,Financial abuse +ES147314,385152,NF,6/4/2014,Evidence and interviews indicated facility failed to assure Resident #1's safety on 06/04/2014 when Resident #1 left the facility without assistance.,2,,Not Substantiated,Substantiated, +OR0000969201,385152,NF,5/14/2015,"Evidence and interviews indicated facility failure to ensure adequate bowel care according to facility protocol and physician orders for Resident #3. Resident #3 had no recorded bowel movements from 11/15/14 through 11/20/14 and there was no evidence the facility conducted a constipation assessment or timely contacted a physician regarding facility protocol. + + + +The facility failure to provide Resident #3 adequate bowel care and treatment resulted in Resident #3 sustaining impaction and unreasonable discomfort, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,300,Substantiated,Substantiated,Neglect +OR0000969203,385152,NF,5/14/2015,Evidence and interviews indicated facility failure to adequately implement the care plan for bed mobility for Resident #3. Resident #3's 11/2014 care assessment indicated she/he required two people and extensive assistance for bed mobility. Documentation for Resident #3 indicated from 11/21/2014 through 11/25/2014 one CNA moved Resident #3 in bed 10 out of 13 times. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000971501,385152,NF,5/21/2015,"Evidence and interviews indicated facility failure to implement additional interventions after a fall with injury for Resident #2 who had a fall with fracture. Resident #2 sustained a second fall and an additional fracture. The facility failure to implement adequate fall interventions resulted in Resident #2 sustaining falls with fractures, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +ES153538,385152,NF,11/7/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from theft of her/his coin purse with money (approximately $15), a first edition Kennedy coin, and a Marine Corp item of sentimental value by an unknown perpetrator on or about 11/7/2015. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining loss of money is a violation of resident rights, considered financial exploitation, and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +OR0000655400,385155,NF,12/21/2010,The facility failed to administer Resident #1_x001A_s insulin as ordered resulting in Resident #1 experiencing a significant change of condition requiring hospitalization. Federal penalty recommended; relevant portions of the survey report are attached.,3,2500,Substantiated,Substantiated,Neglect +OR0000677900,385155,NF,3/23/2011,Based on interviews and record review it was determined facility failed to follow standards of practice for the administration of a Fentanyl patch for Resident #1. Based on interviews and record review it was determined the facility failed to ensure Resident #1 was free from unnecessary medication. Federal penalty recommended; relevant portions of survey report are attached.,3,0,Substantiated,Substantiated,Neglect +HB128968,385155,NF,1/12/2012,"Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 and Resident #2 on January 2, 2012. Resident #1 and Resident #2 had an altercation in the dining room resulting in Resident #2 sustaining bruises.",2,0,Substantiated,Substantiated,Neglect +OR0000754200,385155,NF,4/4/2012,"Evidence and interviews indicated facility failed to ensure Resident #1 received adequate care a services resulting in Resident #1 sustaining a fall on 04/02/2012. Resident #1 sustained a fractured hip requiring hospitalization. Relevant portions of the complaint survey are attached, federal penalty recommended.",3,0,Substantiated,Substantiated,Neglect +HB120032,385155,NF,5/11/2012,"Resident #1 had a history of constipation. On or about May 11, 2012, RP2 (CNA) inserted her/his finger into Resident #1's rectum to assist Resident #1 in voiding stool. This procedure is outside of RP2's scope of practice.",2,0,Not Substantiated,Substantiated, +HB121503,385155,NF,11/3/2012,Evidence and interviews indicated facility failure to ensure RP2 (CNA) followed Resident #1's care plan when assisting Resident #1 with peri-care. RP2 failed to listen to and respect Resident #1's request resulting in Resident #1 sustaining a loss of dignity.,0,0,Not Substantiated,Substantiated, +HB121138,385155,NF,9/23/2012,Evidence and inRP2 (administrator) failed to ensure a safe environment for Resident #1 on 09/23/2012 resulting in Resident #1 sustaining a loss of human dignity.,2,250,Substantiated,Substantiated,Verbal/Mental abuse +HB121371,385155,NF,10/22/2012,"On or about 10/22/2012 Resident #1 was observed by facility staff (licensed nurse) to have two small bruises on her/his jaw line. Facility was unable to determine the cause of Resident #1's jaw line bruises. Resident #1's November, 17, 2011 In Room Care Plan indicated she/he had a history of self injury and self-inflicted bruises. There were no interventions in place for what staff were supposed to do if Resident #1 was found attempting to self-injure her/himself. Facility failed to adequately care plan interventions, failing to ensure a safe environment for Resident #1.",2,0,Not Substantiated,Substantiated, +HB121897A,385155,NF,12/17/2012,"Evidence and interviews indicated facility failed to ensure Resident #1 received an ordered pain medication at 6 a.m. on 01/02/2013. Pain medication was available in the emergency kit however Resident #1 was not administered the medication. Resident #1 received the ordered pain medication at 4 pm on 01/02/2013. Resident #1 was observed to be in pain and uncomfortable during the day on January 2, 2014.",2,0,Substantiated,Substantiated,Neglect +HB132670,385155,NF,3/14/2013,"Resident #1_x001A_s care plan indicated facility staff were to provide two-person transfer assistance with a Hoyer lift. On 03/14/2013 RP2 (CNA) transferred Resident #1 from a wheelchair onto the bed by using a draw sheet and sliding Resident #1 from the wheelchair to the bed. During Resident #1_x001A_s transfer she/he sustained a skin tear on the arm. + + + +The facility failure to provide a safe environment and ensure facility staff followed Resident #1_x001A_s care plan resulting in Resident #1 sustaining skin injury are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +OR0000816001,385155,NF,3/5/2013,,3,0,Substantiated,Substantiated,Neglect +OR0000820000,385155,NF,3/25/2013,Evidence and interviews indicated facility failure to implement interventions and/or assistive devices for Resident #2 and Resident #3 resulting in both Residents sustaining injury Relevant portions of the complaint report investigation are attached.,2,500,Substantiated,Substantiated,Neglect +HB134206,385155,NF,8/23/2013,Evidence and interviews indicated Resident #1 was admitted with $200.00 in cash and Resident #1 declined an offer to lock her/his money up. Resident #1's family member reported she/he was missing $145.00 approximately two days after Resident #1's admission the facility.,2,,Not Substantiated,Substantiated,Financial abuse +OR0000862700,385155,NF,11/8/2013,"Evidence and interviews indicated facility failure to timely respond to Resident #1's pain resulting from a fractured hip, resulting in Resident #1 sustaining unaddressed pain. These failures are violations of resident rights, are considered neglect of care and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +HB145938,385155,NF,1/30/2014,Evidence and interviews indicated facility failure to maintain an adequate medication management system related to a 01/29/2014 incident where staff failed to reorder Resident #1's routine narcotic pain medication. Resident #1 was not given her/his 8 pm dose of the routine pain medication on 01/29/2014. Resident #1 was given the routine pain medication before 10:30 pm on 01/29/2014.,2,,Not Substantiated,Substantiated, +OR0000885501,385155,NF,3/25/2014,Evidence and interviews indicated facility failure to follow physician orders regarding blood tests for Resident #1. Facility failure to ensure Resident #1 received blood testing as ordered by a physician placed Resident #1 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,350,Not Substantiated,Substantiated, +OR0000885503,385155,NF,3/25/2014,"Evidence and interviews indicated facility failure to provide Resident #1 an opportunity to participate in planning her/his care. + +Facility failure to ensure Resident #1 was provided an opportunity to participate in planning her/his care placed Resident #1 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000888300,385155,NF,4/7/2014,"Evidence and interviews indicated facility failure to follow physician orders for the treatment of Resident #2_x001A_s surgical incision as ordered by the physician. March 2014 treatment administration records contained no documentation Resident #2_x001A_s medical treatments were completed on 03/14/2014, 03/20/2014, 03/21/2014, 03/24/2014, 03/25/2014 and 03/27/2014. In addition, evidence and interviews indicated facility failure to ensure the arrangement of Resident #2_x001A_s 3/21/2014 post-op return appointment to the neurosurgeon. The facility failure to follow physician orders for Resident #2_x001A_s treatment placed Resident #2 at risk for unmet needs. Relevant portions of the complaint report are attached.",3,250,Not Substantiated,Substantiated, +OR0000885502,385155,NF,3/25/2014,"Evidence and interviews indicated facility failure to provide reasonable accommodations for the safe and comfortable transfer of Resident #1 related to a 05/072014 incident. Facility failure to ensure Resident #1 received adequate timely, adequate transfer accommodations to the local emergency hospital for treatment, placed Resident #1 at risk of delayed treatment. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +HB147009,385155,NF,5/7/2014,"Evidence and interviews indicated that RP2 (CNA) was counseled about her/his voice inflection being ""gruff"" and approach being ""abrupt"" with residents at times. RP2 said she/he was not provided training regarding her/his voice inflection and approach with residents. Resident #1 said she/he was fearful of contact with RP2 due to her/his demeanor and tone of voice. Evidence and interviews indicate facility failure to provide qualified staff to assist Resident #1 with her/his care needs.",2,,Not Substantiated,Substantiated, +HB147308,385155,NF,6/5/2014,"Evidence and interviews indicated RP2 (Administrator) failed to treat Resident #1 with consideration, respect and dignity when providing care related to an incident on or about 06/05/2014. Evidence and interviews indicated RP2 told Resident #1 she/he would take away Resident #1's cardiac chair if Resident #1 did not change her/his behavior. Evidence and interviews indicated minimal and/or inadequate care planning regarding Resident #1's documented behaviors resisting care assistance.",2,,Not Substantiated,Substantiated, +OR0000900901,385155,NF,6/3/2014,Evidence and interviews indicated facility failure to follow physician orders for Resident #1_x001A_s wound treatment and labs. The facility failure to follow physician orders for Resident #1_x001A_s wound treatment placed Resident #1 at risk for complications from the pressure ulcer. Relevant portions of the complaint report investigation are attached.,3,250,Not Substantiated,Substantiated, +HB148790,385155,NF,10/3/2014,"Evidence and interviews indicated facility failure to protect Resident #1 from financial exploitation resulting in the theft of Resident #1's money. On 10/3/2014, Resident #1 asked RP2 (CNA) to assist her/him in withdrawing $500.00 from Resident #1's checking account. RP2 withdrew $700.00, in three separate amounts from Resident #1's checking account on 10/3/2014. After returning to the facility, Resident #1 determined $200.00 of the money was missing. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining loss of money is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,400,Substantiated,Substantiated,Financial abuse +HB148607,385155,NF,9/18/2014,"Evidence and interviews indicated facility failure to provide Resident #1 a safe environment. On or about 9/18/2014 Resident #1 requested call light assistance however when RP2 (CNA) arrived to assist Resident #1 she/he had urinated in her/his bed. Evidence and interviews indicated that RP2 became upset while assisting Resident #1 and Resident #1 reported the incident to witness #2 (licensed nurse). Witness #2 removed RP2 from providing care for Resident #1 that evening, however failed to follow-up on Resident #1's complaints regarding RP2 and failed to report the complaint. The Facility failure to provide a safe environment for Resident #1 resulting in Resident #1_x001A_s loss of dignity is a violation of resident rights are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +HB159763,385155,NF,1/2/2015,Evidence and interviews indicated facility failure to assure Resident #1's safety related to circumstances on 1/1/2015 where Resident #1 left the facility without assistance. Resident #1 was a known risk for wandering and her/his wheelchair alarm failed to sound when she/he left the facility. Facility staff located Resident #1 sitting outside nearby the facility in the early morning.,2,,Not Substantiated,Substantiated, +OR0000952000,385155,NF,3/5/2015,"Evidence and interviews indicated facility failure to assess changes in Resident #1's medical condition and her/his skin status and the facility failed to notify the physician in a timely manner. Resident #1 was hospitalized in critical condition, placed on hospice and died. The facility failure to provide Resident #1 adequate care and services related to assessing and monitoring Resident #1's change in medical condition resulting in Resident #1 requiring hospital treatment for a critical medical condition are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +OR0000952001,385155,NF,3/5/2015,"Evidence and interviews indicated facility failure to assure Resident #1 was properly hydrated. Evidence and interviews indicated facility failure to assess Resident #1 for dehydration and ensure proper fluid intake. In addition, evidence and interviews indicated facility failure to maintain complete meal monitor records and accurate care planned interventions for Resident #1.Resident #1 was hospitalized in critical condition, placed on hospice and died. The facility failure to provide Resident #1 adequate care and services regarding dehydration resulting in Resident #1 requiring hospital treatment for a critical medical condition are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000966301,385155,NF,4/28/2015,"Evidence and interviews indicated facility failure to assess changes in Resident #2's medical condition and her/his skin status and the facility failed to notify the physician in a timely manner. Resident #2 was hospitalized in with a severe infection, diagnosed with sepsis with shock, acute renal failure and dehydration. The facility failure to provide Resident #2 adequate care and services related to assessing and monitoring Resident #2's change in medical condition resulting in Resident #2 requiring hospital treatment for a critical medical condition are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,2500,Substantiated,Substantiated,Neglect +OR0000966302,385155,NF,4/28/2015,"Evidence and interviews indicated facility failure to provide Resident #2 adequate care and services related to dehydration. Resident #2 was hospitalized in with a severe infection, diagnosed with sepsis with shock, acute renal failure and dehydration. The facility failure to provide Resident #2 adequate care and services related to dehydration resulting in Resident #2 requiring hospital treatment for a critical medical condition are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0001047100,385155,NF,1/5/2016,"Evidence and interviews indicated facility failure to obtain adequate care and services for Resident #1 who sustained an unwitnessed fall on or about 12/31/2015. The facility failure to provide Resident #1 adequate care and services related to falls, resulting in delayed wound treatment, is a violation of resident rights, considered neglect of care, and constitutes abuse. In addition, evidence and interviews indicated facility failure to adequately investigate and report falls and facility failure to follow care planned fall interventions, timely care plan services, updates to care plans and orthostatic blood pressures for Resident #1, Resident #2, and Resident #3. The facility failure to provide adequate fall intervention care and services placed Resident #1, Resident #2, and Resident #3 at risk for continued incidents and injury. In addition, evidence and interviews indicated facility failure to have a Quality Assessment and Assurance committee with a physician and Director of Nursing Services meeting on a quarterly basis to address residents continued falls. This failure placed residents at risk of unmet needs due to unidentified and/or unaddressed issues with the facility_x001A_s care systems; relevant portions of the complaint report investigation are attached.",3,800,Substantiated,Substantiated, +OR0001047102,385155,NF,1/5/2016,Evidence and interviews also indicated facility failure to provide adequate hygiene care and services for Resident #1. This failure placed Resident #1 at risk for complications from poor hygiene; relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000653000,385156,NF,12/9/2010,"Resident 1 did not receive oral medication following re-admission of 11/30/10. On 12/1/10 the oral medication was ordered 4 times per day in addition to the PRN, but was not transcribed to the MAR or TAR. Staff reported Resident 1 did not display signs of pain on 12/1/10 and did receive the PRN oral medication between 11/30/10 and 12/3/10. Resident 1 was at risk for increased pain as staff requested the scheduled medication as Resident 1 often did not report pain. The process for transcribing and noting orders was amended to use of two staff. Relevant portions of the survey are attached. A plan of correction was submitted.",2,0,Not Substantiated,Substantiated, +OR0000658800,385156,NF,1/4/2011,"Resident 4 was admitted with multiple diagnoses including a left hip replacement, cognitive impairment and a history of a right hip replacement. On 12/10/10 PT assessed Resident 4's left leg as being shorter than the right and documentation of Resident 4's inability to bear weight on the left leg. Staff 7 stated he/she documented the leg difference, but did not notify the physician. Resident 4 was sent to the ER on 12/14/10. Staff 8 noted Resident 4's left hip flexion and internal leg rotation on 12/13/10, but did not notify the NP. Resident 4 was receiving a scheduled narcotic pain medication during this time. Relevant portions of the survey are attached. Enforcement action was proposed and a plan of correction was submitted.",2,0,Not Substantiated,Substantiated, +ES116047,385156,NF,12/30/2010,"Facility staff failed to ensure W2 was properly trained to give RV's insulin. RV missed 4 doses of short acting insulin, but did take oral diabetic medication. RV and W2 could have called Home Health or insisted facility licensed staff teach W2 rather than simply assume Home Health was coming out 12/20/10. RV stated he/she was not frightened and did not feel bad. W3 ensured emergency training for W2 so RV did not miss anymore insulin. RP2 only took W2's word he/she could give RV's insulin. No facility licensed staff trained or observed W2's ability to give the insulin. RV was at risk for harm when missing the insulin.",2,0,Not Substantiated,Substantiated, +ES116193,385156,NF,12/2/2010,Staff failed to adequately document and notify RV's physician and hospice regarding RV's refusal of medication. There has been inadequate staff training and or care plan regarding the best approach for getting RV to accept his/her medication. RV is at risk for harm when not consistently receiving his/her medications.,2,0,Not Substantiated,Substantiated, +ES116570A,385156,NF,3/12/2011,RV was admitted to the facility on 3/14/11 at 3:30 P.M. for rehabilitation following surgery. RV reported being left at the bed side and experiencing a great deal of pain. RV reported not receiving his/her requested pain medication in a timely manner. RV's prescription pain medication was not given until 19:40 (7:40 P.M.). RV suffered unnecessary discomfort and pain.,3,300,Substantiated,Substantiated,Neglect +OR0000673700,385156,NF,3/3/2011,"Resident 1 was admitted 2011 with diagnoses including end stage renal disease. Resident 1 's care plan revealed use of a wheel chair with leg rests and foot pedals. On 3/21/11 the surveyor observed another wheel chair in Resident 1's room which was not care planned. Not all staff knew when to use the tilt in space chair. Resident 1's care plan dated 2/14/11 revealed no documentation of fall risk or interventions to reduce the potential for falls. On 2/26/11 Resident 1 left for a dialysis appointment, resident fell out of the wheel chair and sustained a fracture. The transport company had contacted the facility on 2/17/11 regarding Resident 1's having an on going risk to slip out of the wheel chair. The facility failed to contact the transport company or care plan for Resident 1's fall risk. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +ES116761,385156,NF,4/8/2011,"The facility failed to ensure RV understood that he/she was responsible to pick up medication at the pharmacy. RV did not have medication for three days causing ""RV's body to freeze up a little."" evidence is inconclusive whether or not RV had medication left when he/she left the facility. RV was at risk for harm when he/she went without his/her medication.",2,0,Not Substantiated,Substantiated, +ES117359B,385156,NF,6/25/2011,"RP3 was told of possible inappropriate contact but failed to immediately report to supervisors, LEA or SPD. RP3 did not believe the reported alleged event occurred and told RP2 to report to management. RP3 reported attempting to contact family, but failed to place on the 72 hour report. RP2 left an urgent message for his/her supervisor. RP2 and RP3 were suspended.",2,0,Not Substantiated,Substantiated, +ES117971,385156,NF,9/9/2011,"Resident #1 (RV1's) care plan updated on 9/8/2011 noted that RV1 exhibited both physical and verbal aggression. One planned approach was to find a quiet place for RV1 away from other residents. None of the approaches recommended the use of physical force. On or about 9/9/2011 Reported Perpetrator #2 (RP2) came across a situation in which RV1 was agiitated and grabbing at another resident's wheelchair. RP2 intervened and, in the process, struck RV1 in violation of RV1's care plan. Evidence is insufficient to determing whether there was a negative outcome to RV1. RP2's action constituted physical abuse.",2,0,Not Substantiated,Substantiated,Physical Abuse +OR0000722701,385156,NF,10/24/2011,"Resident 2 was admitted 7/20/11 with diagnoses including dementia. Resident 2's safety awareness and limitations to her/his abilities were recognized. Resident 2 sustained a number of falls; some with injury and some without injury. Resident 2 sustained a serious injury fall on 10/21/11, but Resident 2's POA was not notified of the fall until 10/22/11. W2 (POA) stated he/she wanted to be notified immediately of something so serious and did not believe ""they had the right to send resident out for treatment without his/her permission."" staff failed to notify the resident's significant other as soon as possible when Resident 2 sustained an injury. Relevant portions of the survey are attached. Enforcement action was recommended.",2,0,Not Substantiated,Substantiated, +OR0000728001,385156,NF,11/16/2011,Resident 1 was admitted 10/31/11 with multiple diagnoses and an assessed fall risk. Resident 1 fell on a number of occasions and was transferred to the hospital the evening of 11/11/11. Resident 1's POA was not notified of the 11/11/11 fall until the hospital called. Staff 14 reported hesitancy to leave a message regarding the resident. Resident 1's choice in treatment was ultimately not honored when the POA was not notified and allowed to provide choice for the resident. Relevant portions of the survey are attached. Enforcement action was proposed.,2,0,Not Substantiated,Substantiated, +OR0000745400,385156,NF,2/16/2012,"Resident 169 was admitted 10/10/2011 following a hospital visit. The hospital transfer form for the resident indicated a fall risk, confusion, impulsivity and need for frequent checks. The resident temporary care plan of 10/12/2011 and fall care plan revealed risk for falls with multiple interventions, but the in room care plan and comprehensive plan did not provide intervention. Resident fell on 11/7/2011, sustained a head injury and was transferred to the ER for evaluation. The facility failed to thoroughly investigate the fall by failing to interview all pertinent staff. Staff gave conflicting information regarding implementation of the fall interventions at the time of the resident's falls. Relevant portions of the survey are attached. Enforcement action was proposed and facility failure represents Oregon Administrative rule violation.",2,0,Not Substantiated,Substantiated, +OR0000746100,385156,NF,2/21/2012,"Resident 268 was admitted 2/9/2012 with multiple diagnoses and physician ordered medications. On 2/18/2012 Staff 5 gave Resident 268 his/her roommates medication after asking resident if his/her name was ""Virginia"" and resident confirmed that it was. The facility did not use wrist bands or photo ID for residents receiving medication. After this event wrist bands, pictures and verbal address to residents was changed to improve resident safety in receiving medication. Staff provided Resident 268 with monitoring, transfer for evaluation and later discharged that evening. Relevant portions of the survey are attached. Facility failure represents a Oregon Administrative rule violation and a federal civil penalty was proposed.",3,0,Not Substantiated,Substantiated, +OR0000747200,385156,NF,2/29/2012,Resident 266 was admitted on 9/3/2011 with multiple diagnoses. A nursing note of 9/14/2011 on day shift revealed lung sound changes and oxygen at two liters . A 9/14/2011 physician order specific to medication and record review found medication doses were missed. Resident was sent to the hospital on 9/15/2011 due to shortness of breath. Relevant portions of the survey are attached. The facility failure represented an Oregon Administrative rule violation. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000747201,385156,NF,2/29/2012,Resident 266 was admitted 9/3/2011 with multiple diagnoses including staples in three incisions. Physician orders directed staff to remove staples 14 days postop; staff failed to follow the physician orders. On 9/15/2011 staff noted the incisions as clean and dry with staples in place. Resident was admitted with a Stage II decubitus ulcer and the physician ordered treatment was not initiated until 9/12/2011. resident had three Stage II ulcers to the left buttocks on 9/15/2011. The facility failed to transfer the ulcer treatments to the TAR and the resident's ulcers deteriorated and or developed into a Stage II. The facility failure constitutes abuse and a Oregon Administrative rule violation. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000751900,385156,NF,3/26/2012,"Resident #265 (known as resident) was readmitted to the facility on 8/17/2010 with multiple diagnoses. Staff found the resident sitting on his/her room floor at 6:05 P.M. without redness or open area and resident denying he/she struck his/her head. Resident did not show signs of pain or injury at the time staff completed range of motion; or while standing; and or while moving his/her legs. Resident began complaining of severe pain at 11:30 P.M., received medication including narcotic pain medication with some moderate relief. Nursing notes at 4:00 A.M. reveal resident stating pain was due to the fall. Staff failed to notify resident 's physician at the time. Resident received pain medication again at 4:30 and 8:30 A.M. Resident was still painful and staff sent a fax to the FMP, but the resident was not examined until 4:00 P.M.; almost 24 hours after resident's fall. Resident did not receive timely assessment and treatment for resident's complaint of severe pain. The resident was sent to the hospital. The facility failure represents an Oregon Administrative Rule violation and a F-Tag citation. Relevant portions of the survey are attached. A federal civil money penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +ES120080A,385156,NF,3/15/2012,"RV did not receive his/her replacement pain medication patch on 5/3/2012, but received a new pain medication patch on 5/4/2012. RV complained of increased pain due to not receiving the pain patch on 5/3/2012. The facility failed to ensure a safe medication system to assure the pain medication patch was properly ordered and available for RV. RV sustained unnecessary pain and discomfort. The facility failure represents an Oregon Administrative Rule violation.",3,450,Substantiated,Substantiated,Neglect +ES117279,385156,NF,6/21/2011,RV was admitted with complex medical issues. Record review found medication changes and medication given as ordered. RV's care plan indicated toileting assists per RV's request. RV reported waiting long periods of time when calling for assistance to the toilet. RV's right to choice in treatment was not always honored due to poor call light response. The facility call log form 5/16 through 5/24/12 for RV revealed 19 times a wait of 20 minutes or more. The facility is working with staff to improve call light response time. The facility failure is an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +ES118167C,385156,NF,10/4/2011,"RV, W1 and W3 confirm RV has complained he/she waited nearly 4 hours after requesting pain medication. RV requested pain medication at 5:30 A.M. and did not receive the medication until 9:30 A.M. W9 was in the middle of a medication count and believed he/she told day shift nurse of RV's request. W10, day shift nurse) does not recall specifics, knows RV has real pain and responds quickly, but may have misunderstood the night nurse. W12 does not recall specifics, but does believe RV had to wait four hours. RV did not receive medication in a timely manner. This facility failure is a Oregon Administrative Rule violation.",0,0,Not Substantiated,Substantiated, +ES118167A,385156,NF,10/4/2011,The facility failed to provide sufficient staffing to meet RV's need for timely assistance to the commode. W3 was visiting RV and provided assistance to the commode after waiting half an hour for the call light to be answered. The facility was instituting a new protocol to address call light time response reduction. The facility failure is a Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +ES118167B,385156,NF,10/4/2011,RV and W3 reported RV was left in his/her wheel chair in the dining room for more than hour after meals. Witnesses and RV reported not enough staff to assist RV back to his/her room and sometimes RV's roommate will assist RV back to his/her room. RV complained of pain if left sitting too long in the wheel chair. RV's care plan was adjusted to address RV's needs. The facility failure represents an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +OR0000786501,385156,NF,9/28/2012,"Resident 1 was admitted 8/24/2012 with multiple diagnoses. Resident 1's physician orders indicated oxygen titration 92% without specific liters of oxygen. Resident's initial data collection indicated the resident used two liters of oxygen. W1 reported staff did not discuss the trial reduction of oxygen below the two liters. The resident was unavailable for interview. Staff 3 reported the resident should have been informed of the oxygen reduction. The resident did become anxious, the oxygen saturations stayed above 92%, staff increased the oxygen back to two liters. Additionally the resident received a PRN Xanax without documentation noting use of non-pharmaceutical interventions first. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000786503,385156,NF,9/28/2012,Resident 1 was admitted 8/24/2012 with multiple diagnoses. The resident did not receive two showers per week as care planned. There is no documentation that the resident was asked if he/she wished to bathed between 9/3/2012 and 9/15/2012. The resident refused a shower on 9/21/2012 and no other bathing was offered up to and including the day of discharge. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +ES118351,385156,NF,10/17/2011,"Evidence remains inconclusive whether or not RV's ring was taken or lost at the facility or at an outside facility. The facility failed to ensure an inventory list was completed, failed to ensure a complete investigation, failed to report the alleged missing item in a timely manner and failed to follow-up with LEA. This facility failure represents an Oregon Administrative Rule violation.",2,0,Inconclusive,Substantiated, +OR0000797400,385156,NF,12/10/2012,"Resident 1 was admitted 2011 with multiple diagnoses including a history of falls, non- ambulation, etc. Resident's care plan on 11/22/2012 indicated ADL function issues and required staff assistance for bed mobility, transfers, dress, etc. The resident sustained fall from the wheel chair on 10/29/2012 while being assisted down the hall way in a wheel chair; legs became tired, feet dropped and the resident fell forward out of the wheel chair. The resident care plan was updated to include use of foot pedals at all times. On 12/7/2012 Staff 4 assisted the resident down the hallway toward the dining room when the resident's toe caught on the floor and the resident fell forward out of the wheel chair sustaining a large hematoma to the forehead. Staff 4 admitted not recently looking at the resident care plan; told the investigator the in room care plan was not in the ""holder"" until Yesterday (12/11/2012) and stated the resident did not want the foot pedals down. The resident reported staff was rushing and he/she did not have time to tell the CNA to put the pedals down. Reviewer notes Staff 4 should have checked the notebook if the care plan was not available in the resident's room. Staff received further in-service. Relevant portions of the survey are attached. A civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +ES132230,385156,NF,1/7/2013,The facility failed to ensure RV's call light in particular was answered in a timely manner. This failure resulted in RV's incontinence and or RV sitting in his/her own feces and or urine for periods of time extending beyond half an hour. Failing to provide prompt toileting assistance resulting in incontinence; and or prompt incontinence care is neglect of care and constitutes abuse. An Oregon Administrative Rule violation occurred.,2,200,Substantiated,Substantiated,Neglect +OR0000825300,385156,NF,4/23/2013,"Resident 3 was admitted 2012 with diagnoses including ALS. Resident care plan dated 11/12/12 noted skin at risk. The 12/23/2012 room care plan identified the resident as a two person Hoyer transfer using a medium sling. A nursing note of 4/18, 2013 indicated the resident ""slipped"" from the sling during a transfer and the subsequent x-ray noted a right humerus fracture. Staff 2 wrote a note stating she/he had switched the ""large sling"" for a medium sling to avoid another event. The facility failed to ensure the appropriate size sling was available and used by all staff. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +ES133439D,385156,NF,5/28/2013,"RV sustained a large skin tear to the left buttocks of an unknown origin. W7 stated the skin tear was due to use of a slide board, but all staff deny use of a slide board. RV's care plan indicated a two person Hoyer transfer, but witnesses reported seeing a two person pivot transfer at times. The facility failed to ensure RV's care was provided as care planned. RV sustained a large skin tear constituting neglect of care and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES133439E,385156,NF,5/28/2013,"RV was admitted 5/28/2013 with a hospital history of possible eye infection and a note regarding use of eye drops, but no discharge order for eye drops. Routine eye drops were ordered 5/30/2013 and to end 6/6/2013; then use PRN. RV's MAR indicated a 5/29/2013 order for normal saline eye drops every two hours; may leave at the bedside. No MAR's May description record was found. Some departmental notes were found, but not indicating use of the drops every two hours. The facility failed to give the eye drops as ordered and or properly record use of the eye drops. Improper use or documentation of RV's eye drops placed RV at risk for harm. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES133439F,385156,NF,5/28/2013,"RV was admitted 5/28/2013. RV's treatment record of May 2013 indicated monitoring of RV's left calf for weeping. No staff initials or notes were found on the Treatment Account Record (TAR) from 5/28/2013 to 5/31/2013. A 5/28/2013 departmental note indicated bilateral 3 to 4+ edema of the lower legs, as well as, a small area on the left medial calf that weeped. Staff did not provide treatment to RV's weeping legs until a 5/31/2013 department note indicated a wrap was applied and evening staff were to notify the PCP. Staff notified the GNP of edema and weeping on 6/1/2013 (12:17 A.M.). On 6/1/2013 (1:15P.M.) RV sustained a ""small tiny slit to the left medial lower leg""; no indication the PCP or GNP were notified. Staff did not provide timely follow up when the PCP and or GNP failed to promptly reply to staff inquiry regarding treatment of RV's weeping lower left leg. The PCP did not respond until 6/3/2013. RV was at risk for infection when staff treated RV's weeping legs that showed an open skin area without specific physician orders. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES133439A,385156,NF,5/28/2013,"RV was admitted 5/28/2013 and sustained chronic nausea/vomiting from admission per W3. W3 reported day shift took away RV's emesis basin, forgot to replace the basis and RV vomited on self. W4 reported RV would feel fine and suddenly vomit. The facility failed to ensure RV had proper equipment (emesis basin) at all times resulting in RV vomiting on self. RV was left with vomit on self at meal time. A reasonable person would be uncomfortable being left with vomit on themselves, let alone at meal time. RV was not afforded choice in care and sustained loss of dignity constituting neglect of care and abuse. Oregon Administrative Rules were violated.",2,700,Substantiated,Substantiated,Neglect +ES134857A,385156,NF,10/1/2013,RV was unable to give relevant information regarding missed medication. The facility staff failed to place RV's specific medication on the MAE and RV did not receive the medication from 10/1/2013 to 10/15/13. when the facility caught the error RV's physician was informed an treatment was initiated as physician ordered. No evidence was found to substantiate a negative outcome to RV. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +ES149058,385156,NF,9/2/2014,"RV reported not being told about a blood clot, but went home on a blood thinner. RV was unable to recall dates of events. RV's stay was extended due to RV's complaint of pain/swelling, prompt assessment, physician notification and treatment including use of blood thinning medication was provided. W1 (staff) and RV's medical record including discharge did not indicate RV was instructed regarding the blood clot or blood thinning medication. RV was at risk for harm when staff failed to provide adequate discharge instructions. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES134292,385156,NF,8/20/2013,"The complainant voiced concerns including call light dysfunction, incontinence care was not timely and RV has fallen twice. RV does not recall falling, but does recall the call light not functioning and was given a hand bell. RV reported waiting the longest time of 15 minutes for incontinence care. W2 reported being with RV one time and it took approximately 60 minutes for staff to respond to the call light. RV did sustain two unforeseeable falls without noted injury. W7 reported RV had a light rash which could have developed during transport. RV's call light did break and required repair. RV's call light was not always answered timely and at least one time RV sustained discomfort. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ES149752,385156,NF,12/31/2014,"Staff reported to RV's call light, but due to shift change and RP3 assisting another resident it took additional time to respond to RV's needs. RV did not express discomfort, but did express worry. RV's choice for more timely call light response was not met resulting in risk of harm. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000917700,385156,NF,8/26/2014,Resident 3 was admitted 2014 with multiple diagnoses including encephalopathy. The resident in room care plan dated 8/4/2014 did not address checking or repositioning the resident frequently while witting on the edge of the bed. Staff 2 acknowledged the in room care plan was not updated to reflect resident need. The resident was placed at risk for harm. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000917701,385156,NF,8/26/2014,Resident 3 was admitted 2014 with multiple diagnoses including diabetes. W6 stated the resident was not provided dinner for 1.5 hours after insulin was administered. The resident's CBG was to checked at 4:30 P.M. and dinner insulin given at 5:00 P.M.. Dinner was served at approximately 5:30 P.M. Per review the resident's CBG and insulin was given at indicated time frames. Based on record review it was found the resident received Metformin after the medication was discontinued and the resident's physician was not notified when resident's CBG was less than 70 or greater than 300. the facility failure to ensure all treatment was given as ordered placed the resident at risk for harm. Relevant portions of the survey are attached.. Enforcement action was proposed. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000917702,385156,NF,8/26/2014,Resident 3 was admitted 2014 with multiple diagnoses and orders including CBGs. Staff 5 failed to wear gloves when checking resident's CBGs. Staff 2 was aware Staff 5 failed to use gloves. Resident 3 and other residents requiring CBGs were placed at risk for infection when staff failed to wear gloves during the CBG. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000919000,385156,NF,9/3/2014,"Resident 37 was admitted in July 2014 with multiple diagnoses including diabetes, knee replacement and anxiety. The resident's 7/10/2014 care plan indicated resident required assist with all ADLs except meals. Nursing notes dated 7/10/2014 at 11:20 A.M. indicated the resident ""pitched out of the wheel chair"" and some complaint of left knee discomfort, but no physician notification. The resident RCM notified the physician 14 days later. Relevant portions the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000958100,385156,NF,3/26/2015,"Resident 137 was admitted February 2015 with diagnoses including multiple myloma. The hospital discharge included continue cancer treatment and the resident was in acute kidney failure. Resident's room care plan initiated 2/24/2015 included skin precautions. On 3/18/2015 a physician communication sheet indicated skin break down to the coccyx and treatment orders. The resident's medical doctor did not identify the type of skin breakdown, the cause or if additional interventions were to be provided. A 3/22/2015 note identified resident's entire buttocks was an unstageable pressure ulcer; no investigation was found to indicate if the resident's care plan was followed. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ES151210C,385156,NF,5/5/2015,RV required specialized equipment to take a shower because of RV's condition. From 4/1/2015 until 5/5/2015 RV mainly received bed baths; RV received three showers during this time. RV did not receive adequate care as evidenced by debris between RV's toes. Oregon Administrative rule violation occurred.,2,,Not Substantiated,Substantiated, +ES150883,385156,NF,4/9/2015,"The facility failed to promptly respond to RV's call light resulting in RV's having to wait for incontinence care. RV reported ""feeling inhuman"" in having to wait while incontinent. The facility failure resulted in a significant loss of dignity for RV which constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000963900,385156,NF,4/17/2015,"Resident 1 was admitted 3/12/2015 with multiple diagnoses including a recent hospitalization. The resident's hospital transfer form, dated 3/11/2015, identified the resident had received Coumadin which was discontinued on 3/12/2015 prior to the facility admission. On 3/20/2015 the resident physician ordered Lovenox 60 mg every 12 hours and Coumadin 2mg at bed time. The resident's family wished not to start the Lovenox or the Coumadin until the family took the resident to the medical center on 3/21/2015. The facility failed to follow discharge orders until 3/23/2015. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000973002,385156,NF,5/28/2015,"Resident 3 was admitted in 2014 with diagnoses including dementia and chronic kidney disease. Resident's physician orders dated 12/23/2014 identified the resident's Foley catheter was to be changed monthly and as need. The resident care plan dated 3/6/15 provided intervention including on going assessment of the resident's urine and catheter. There was no documentation on the catheter or urine assessment by staff. On 5/23/2015 Staff 14 initialed showing he/she changed the catheter when in fact it was Staff 17 that changed the catheter. Staff 17 did not document the change in the TAR or in the progress notes. The resident was sent to the hospital on 5/23/2015 with a change of condition. Staff 12 assessed the resident after the catheter was changed, but failed to document the assessment. Relevant portions of the survey are attached. Federal enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES147836,385156,NF,7/19/2014,RV reported not being sure how many times RV did not receive medication required for RV's out of facility treatment. RV reported not always receiving pain medication at RV's request. Record review and interview indicate RV received PRN medication as ordered. RV did miss one time medication to go with RV on RV's out of facility treatment visit. RV reported self medicating with alternative medication per W6. the facility placed a sign as a reminder to staff to insure RV takes specified medication along to treatment three times per week. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0001007601,385156,NF,9/23/2015,"Resident 3 was admitted 2014 with diagnoses including muscle weakness. W3 reported Resident 3, 4 and 5 reported the facility took 40 minutes to 2.5 hours to answer call lights. Resident 3 reported the call light system was broken and residents sued bells and whistles when needing assistance. Resident 3 reported staff response time has improved. Resident 3 denied any negative outcome to waiting for staff assistance. The facility maintenance log for August 2015 indicated call light malfunction, a new system was ordered and staff provided intervention until the new system was installed. A Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ES152711B,385156,NF,9/1/2015,"Per documentation review and witness interview RV2 received lunch meal late as staff missed RV2. RV2 was placed in the wrong room on the day RV2 changed rooms. RV2 did not sustain notable harm, but RV was at risk for harm. Oregon Administrative Rule violation occurred.",1,,Not Substantiated,Substantiated, +ES165038,385156,NF,3/15/2016,"RV's call light is not always answered timely resulting in wait times extending beyond half an hour. RV reported it is ""degrading"" to be left on the commode for long periods of time; ""not to mention the bruising it causes by sitting on the commode for long periods of time."" Witnesses report having found RV one time with RV's arms being numb from being tangled in the lift straps and RV unable to reach the call light or telephone. Witnesses state long wait times before staff respond to resident rooms. Concerns regarding the new call light system have been identified as causing some delay in responding to resident needs. The facility failure to respond timely to RV's needs resulting in significant dignity issue and numbness in RV's arms constitute neglect and abuse. Oregon Administrative Rule violations occurred.",2,250,Substantiated,Substantiated,Neglect +OR0000642700,385157,NF,11/3/2010,"Resident 1 was admitted with diagnoses including Parkinson, anemia, failure to thrive and chronic pain. Resident 1's care plan interventions included assist for most ADLs and two staff for transfers, hip protectors and a low bed. The Nursing Care Directives for CNAs was not available; not kept as part of the medical record. Resident 1's MDS noted resident resistance to care. Resident 1 sustained falls without adequate re-assessment and or intervention to prevent more falls. Staff forgot alarms and Resident 1 fell sustaining a fractured wrist. Multiple staff thought other staff had obtained the alarm. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +NB116137A,385157,NF,1/4/2011,"RP2 responded to RV1's telling RP2 to ""shut up"" by RP2 telling RV1 to ""shut up"". RP2 failed to treat RV1 with all due respect.",2,0,Not Substantiated,Substantiated, +NB116137B,385157,NF,1/4/2011,"RP2 failed to treat RV2 with respect and dignity by speaking to RV2 in a rude/rushed manner and telling RV2 ""how about I tell you what to do."" RP2 did not allow RV2 to participate in his/her care; did not allow RV2 to direct care regarding RV2's swollen and painful arm. RP2 pulled RV2's draw sheet ""fast"" causing RV2 undue pain to RV2's arm. RP2 did not follow RV2's care plan interventions for comfort and dignity.",2,0,Not Substantiated,Substantiated,Neglect +NB116137C,385157,NF,1/4/2011,"RV3 has great difficulty communicating verbal speech, but is able to make sounds and communicate non-verbal comments per W1 and W3's statement. RP2 asked RV3 to ""say please"" and then ""mocked"" RV3's sounds. RP2 failed to treat RV3 with respect, and intentionally mocked RV3 in a manner a reasonable person would find offensive and emotionally abusive.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +OR0000673100,385157,NF,3/2/2011,"Resident 1 was admitted February 2011 with multiple diagnoses including a history of falls. Resident 1's assessment of 2/16/11 indicated a high risk for falls and Resident 1 was care planned for a low bed, fall mats, bed/chair alarms and hip protectors. Resident 1 was seated at the nurses station on 2/23/11 when he/she stood up and fell before near by staff could intervene. Resident 1 sustained hip fracture. Staff 3 and staff 5 dressed Resident 1, but failed to apply the hip protectors. Staff reported feeling ""hurried"" to get residents up for breakfast and forgot to check the care plan. All staff received further in-service in regards to checking resident care plans. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +NB116862,385157,NF,4/29/2011,"RP2 failed to follow RV's care plan requiring a two person transfer using a gait belt. RP2 reported W2 assisted with the transfer, but W2 denies this. W2 reported observing RP2 enter RV's room alone and moving RV into bed. W3 reported observing RP2 move RV by him/herself. The bruise to RV's breast area appeared by evening shift or the next day of 4/29/11. RP2 provided care contrary to clear instruction and disregarded RV's safety. Given the evidence it remains unknown as to the exact origin of RV's bruising.",2,0,Not Substantiated,Substantiated, +NB117741,385157,NF,8/14/2011,"Evidence is insufficient to support RV's change in blood pressure directly related to having old medication patch and new medication patch in place, given RV's significant health issues. RV was at risk for harm by having both patches in place. RP2 failed to ensure old patch was remove, but given the physician order dates RP2 may have not known about the old patch and or over looked the old patch when applying the newly ordered patch. Facility licensed staff should have been aware of the old patch at the time of admission given the hospital transfer sheet and or when the skin assessment had been completed. It is unlikely this information was shared with RP2.",2,0,Not Substantiated,Substantiated, +NB120229,385157,NF,5/24/2012,"Licensed staff told W2 to leave RV alone/re-approach. W2 and W3 per written statement conflict in regard to what was said to RV, but RV did report being told to stay in bed after care was given. W2 stated it was due to assisting other residents. Licensed staff did not go and speak with RV. RV was left in bed. Resident rights were not supported, but evidence is insufficient to state RV was forced to stay in bed.",2,0,Not Substantiated,Substantiated, +NB120911,385157,NF,8/16/2012,"RV wanders about the facility in his/her wheel chair, is easily redirected verbally and capable of getting in and out of bed by him/herself per multiple witnesses. Witnesses report RV likes to stay up until around midnight. On 8/16/2012 at about 10:15 P.M. RV was sitting by the nurses station when RP2 told RV to go bed, RV said ""no"" and RP2 raised his her voice to RV about going to bed. Witnesses reported RP2 pushed RV's wheel chair to RV's door and directed staff to put RV to bed. W3 reported sitting with RV and providing RV with milk and cookies; RV was then willing to go to bed. W3 stated he/she did not want to upset RP2 or RV further. RP2 reported attempting to protect RV and other residents. RP2 admitted not asking RV to raise his/her feet during transportation, but did not notice any resistance. RP2 reported RV ""talks all the time"" and did not pay attentions to what RV was saying. RP2 failed to interact with RV in a professional manner and failed to give RV a choice in his/her care. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB120805,385157,NF,8/9/2012,"RV reported receiving good care, cannot remember if medication was given late and is I a lot pain. W3 reported there are times medication is not given for some time; staff were too busy. W2 came in at 6:15 A.M.; requested RP2 give RV pain medication and reported to W1, who came in at 8:00 A.M. that RP2 had not given RV the pain medication. W1 confirmed the medication was poured, but not given by 8:00 A.M.; requested RP2 give the medication; RP2 gave the medication and _x001A_became angry_x001A_ after talking with W1; and walked off. RP2 denied holding medication more than 20 minutes and was busy with a _x001A_G-tube_x001A_ patient. Evidence remains inconclusive as to the reason RP2 was slow in delivering the requested medication; dealing with a resident with low blood sugar, resident with G-tube concerns or _x001A_too busy_x001A_ in general. Evidence is unclear if RV_x001A_s pain increased due to the untimely delivery of pain medication, but late delivery of pain medication indicates an increased time interval in which RV waited for any decrease in pain. The facility failed to ensure RV received a requested pain medication in a timely manner. This failure constitutes abuse and an Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +OR0000785900,385157,NF,9/27/2012,"Resident 1 was admitted August 2011 with multiple diagnoses including atrial fibrillation and osteoporosis. Resident's care plan required a two person assist with all transfers. On 9/21/2012 Staff 1 (RP2) stated he failed to read the resident's care plan, attempted a one person transfer when the resident extended his/her legs and the resident's left leg caught on the leg rest attachment point. The resident sustained a left leg laceration requiring a trip to the hospital for sutures and staples. Staff 1 reported transferring the resident alone one time prior to this event. Staff 1 was a fairly new CNA requring close supervision. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure represents an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +NB121277,385157,NF,10/7/2012,Facility staff failed to ensure RV1's leaking feeding tube was reinforced with towels/blankets and or changed. Staff failed to ensure RV1's soiled bedding and personal hygiene was promptly taken care of resulting in RV1 laying in a wet /soiled bed. RV2 did not receive prompt incontinence care. Neither resident sustained skin changes. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +NB132260,385157,NF,1/29/2013,"RV returned from the hospital on 1/10/2013 with an order for Protonix (a proton pump inhibitor which suppresses gastric acid secretions). Facility staff failed to transcribe the order to the MAR or ensure RV received the medication from 1/11/2013 through 1/13/2013. RV's Progress Notes indicate RV sustained an emesis on 1/14/2013 at 10:00 P.M. RV had emesis two more times at 12:30 A.M. and 2:50 A.M. on 1/15/2013. Staff notified the physician and received new treatment orders; however, RV requested to go back to the hospital. RV received treatment at the hospital and returned on 1/16/2013. The facility failure to ensure order clarification, appropriate transcription and medication delivery placed RV at risk for potential serious harm. An Oregon Administrative Rule violation occurred.",2,250,Not Substantiated,Substantiated, +NB133026A,385157,NF,4/20/2013,"RV1 reported RP2 was ""frustrated ""with RV regarding how slow RV was moving on RV's return to bed. RV stated RP2 kept stating RV could do for him/herself. RV reported RP2 left RV on the edge of the bed without a way to call for help. RP2 reported belief RV might fall, guided RV to sit on the bed and asked W4 to assist RV. RP2 reported RV is on spinal precautions so would not touch RV's shoulders. W4 denied RP2 spoke to them, but happened by RV's rooms and provided assistance. Both W4 and RV reported the call light was not in reach. RV was not treated with all due respect for his/her choice of treatment. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +NB133026B,385157,NF,4/20/2013,"While RP3 assisted RV to bed, RP3 failed to properly position RV. RV reported being left near the foot of the bed with his/her feet against the foot board. RP3 stated asking W5 to assist RV, but W5 denies this. RV's positioning occurred on the next shift. RV was a not given all due consideration regarding his/her choice of care. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +NB133026C,385157,NF,4/20/2013,"RP3 told RV2 if he/she did not stop yelling for assistance RP3 would shut RV's door. RV2 is very afraid of being left without care due to RV's ""breathing issue."" RP3 reported using isolation before and it was acceptable practice. RP3's threat of seclusion toward RV2 constitutes emotional/mental abuse. The facility failed to protect RV2 and other residents from RP3's intimidation and or use of involuntary seclusion constitutes abuse. Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Verbal/Mental abuse +NB133142,385157,NF,4/25/2013,"RV reported falling asleep and staff picking RV up and ""manhandling"" RV. RV reported felling safe in the facility. W2 reported RP2 resigned 3 to 4 days after the reported event. W6 reported RV has arthritis, may have experienced pain if lifted and is very hard of hearing. W7 reported RV may have become confused when not using his/her amplifier. W7 stated it was training issue for staff in regard to RV's care plan. Evidence is not conclusive RP2 was rough, but RP2 failed to follow RV's care plan to use the amplifier. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB133996,385157,NF,7/29/2013,$130.00 went missing from RV's wallet between 7/29/2013 and 8/1/2013. RV did not leave the facility or have any visitors during this time frame. The facility reimbursed RV. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Financial abuse +NB133609,385157,NF,6/21/2013,"RV received three times the amount of medication without notable effect. RP2 immediately notified RV, family, physician and APS of the error. RV still had pain even after the amount of medication he/she received. RP2 followed an older physician order. Reviewer notes RV's complain of slow call light response and no showers. RV did receive a bed bath and dry shampoo. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB134252,385157,NF,8/29/2013,RV's sensory fragrance valued at $100.00 went missing from the unlocked activity room. The facility failed to ensure RV's personal possessions were maintained in a safe secure location. The facility replaced the missing fragrance and established a new policy regarding valuables. An Oregon Administrative Rule occurred.,2,,Substantiated,Substantiated,Financial abuse +NB134601,385157,NF,10/3/2013,The facility failed to provide sufficient staffing to meet the needs of the residents. RV1 was not provided showers for six days in September 2013 and missed one shower in October 2013. RV2 missed seven showers and shaves in September 2013 and one shower and shave in October 2013. RV3 and RV4 also missed multiple showers and shaves. Residents were not afforded their choice of care when showers and or shaves were not provided as care planned. The repeated lack of care constitutes neglect of care and abuse. Oregon Administrative Rule violations occurred.,2,450,Substantiated,Substantiated,Neglect +NB135184,385157,NF,11/22/2013,"The complainant and W1 reported RP2 spoke to RV in a demeaning manner. W2 reported RP2 spoke to RV as a parent would to a child. W2 reported RP2 was new to the facility and did not appear to understand how to work with residents with cognitive impairment. RV was unable to give relevant information. RP2 had received training on abuse and neglect. W4 provided interventions and redirected RV; RV did not appear upset. RP2 wrote a statement requesting more training. RP2 did fail to treat RV with all due respect, but the facility was culpable, too in training RP2. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB146853,385157,NF,4/17/2014,"RV reported feeling humiliated and embarrassed when RP2 would not allow RV to hold the cup of medication. RV reported during the second encounter with RP2, RP2 allowed RV to hold the medication and allowed RV to take the pills on his/her own. RP2 did not physically hold RV's hands, but did fail to allow RV choice in his/her care in how RV received medication delivery. RP2 reported fearing RV would spill the medication as RV was ""lethargic"". RP2 reported RV was upset. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB146252,385157,NF,3/5/2014,"RV was assisted to toilet and left without a call light in reach. RV stayed on the toilet ""yelling for help"" for approximately 20 minutes. RV was not assisted in a timely manner and being left without a call light placed RV at risk for harm. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +NB146403,385157,NF,3/17/2014,"The complainant voiced multiple concerns regarding RV's care including showers, linen changes, incontinence care and medication to assist with yeast infections. RV reported not being left in soiled sheets; staff were a little slow answering the call light, but RV was not concerned. RV feels he/she is receiving adequate care, but the night staff had not been putting powder (medication ) on for the last 3 to 4 days. This issue has been fixed. RV's rash is improving. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB147672,385157,NF,7/7/2014,"RV reported RP2 rubbed RV's nipples, that RP2 often ""barged"" into RV's room without knocking and reported RP2 told a story regarding RP2's neighbor's loud ""intercourse"". RV refused to press charges; RV's story changed regarding touch of the breast area. Witnesses deny any complaints regarding RP2 prior to this allegation. RP2 acknowledged ""bumping"" RV's breast and moving away. RP2 reported sharing stories with RV. RP2 crossed boundaries by telling RV the story regarding RP2's neighbor. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB148072,385157,NF,7/22/2014,"RP2 provided restorative care to multiple residents, but failed to correctly document care given. RP2 reported being over whelmed and pulled in multiple directions. W4 reported knowing RP2 gave therapy to RV5 because of RV5's hands. Multiple witnesses report staffing was an issue. Oregon Administrative Rules were violated.",2,,Not Substantiated,Substantiated, +NB149299,385157,NF,11/19/2014,RV placed $25.00 in his/her side table; money went missing. W3 reported the facility does advise residents/families to keep valuables/money locked in the business office. Further inquiry found all residents are offered locking boxes as well as use of the business office. The facility reimbursed the money. RV will now keep his/her money in the business office. Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Financial abuse +OR0000926001,385157,NF,10/13/2014,"Resident 3 was admitted September 2014 with multiple diagnoses including pyelonephritis and a fractured finger. W4 reported the resident had a wound near the right thumb when the physician removed the splint on October 1, 2014, the resident returned to the facility and developed an infection with fever. W6's documentation noted a full thickness pressure ulcer without signs of symptoms of infection when the splint was removed and a referral for a local wound care was ordered. The resident's physician or of 9/10/2014 directed staff to make a appointment with W6 within two weeks. The resident was out of the facility between 9/12/2014 and 9/16/2014. Staff failed to make the appointment within the two weeks despite W6'ds order, as well as, W5's order. The resident was seen by W6 on 10/9/2014 and a full thickness pressure ulcer to the right hand had developed. Relevant portions of the survey report are attached. A civil penalty was recommended. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +NB151484A,385157,NF,6/5/2015,"RV reported RP2 slapped a hand on RV's shoulder and pulled RV backward. W2 reported RV struck RP2 and then accused RP2 of hitting RV. RV reported physical therapy denied RV's request to continue exercises, grabbed RV's right shoulder and pushed RV into the wheel chair. RP2 reported touching RV's shoulder as a tactile clue and denied pushing RV. Written and verbal statements show differences. RP2's approach to RV was not from the front likely startled RV. Staff received further in-service regarding approach to residents. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +NB152627,385157,NF,8/25/2015,"Due to poor intra facility communication RV did not go on a outing. Staff did not tell RV he/she could not go on the outing. There has been more than one incident when RV had to wait for toileting and or transfer assistance. RV's pain medication is ordered as a PRN and RV did receive medication. RP2's voice sounds stern, and RV may have misperceived RP2's voice as other than trying to explain narcotic medication to RV. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +NB153794,385157,NF,12/3/2015,"Per W1 RV has pain associated with his/her disease, RV often calls out with pain during transfers and RV is not capable of directing his/her personal care RP2 and W2 provided care to RV on 12/1/201, RV requested to use the toilet, RP2 suggested using the bed pan and then RV wanted to use the bedside commode. W2 reported RP2 commented ""if can't go on the bed pan how do you expect you'll piss in the toilet"" and "" I would like to go to lunch before 3"". W2 reported RP2 yanked RV's leg and crammed it into a shoe; RV was crying and told RP2 that RP2 was rough. RV reported RP2 is rough and argues with RV, RP2 is always rude, RV was embarrassed and upset by RP2's language and tone. RV also stated not feeling RP2 is abusive. RP2 denied ever working alone with RV, denied treating RV roughly and denied saying anything about hurrying. RP2 failed to treat RV with all due respect causing RV embarrassment. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +PT116737A,385161,NF,3/31/2011,"A care plan for Resident #1 dated 3/26/2011 indicated she/he was independent for transfers, locomotion, toileting and bed mobility. On or about 4/6/2011 Resident #1 attempted to pull her/himself up with grab bars in the bathroom and Resident #1 started to slip. RP2 assisted Resident #1 to the bathroom floor; dropping Resident #1 less than a foot while doing so. Facility documentation indicated Resident #1 was provided as needed pain medication and provided first aide for ""two small skin tears."" RP3 (licensed nurse) assessed Resident #1 after her/his fall. RP3 failed to ensure Resident #1_x001A_s physician was timely notified about Resident #1_x001A_s 4/6/2011 fall. Resident #1's updated 4/7/2011 care plan indicated extensive assistance with transfers, locomotion and bed mobility. Toileting assistance was changed from independent to limited assistance.",2,,Not Substantiated,Substantiated, +PT116737B,385161,NF,3/31/2011,Resident #1 fell on 4/6/2011. RP3 (licensed nurse) assessed Resident #1 after the 4/6/2011 fall. RP3 failed to ensure Resident #1_x001A_s physician was timely notified about Resident #1_x001A_s 4/6/2011 fall. RP3_x001A_s failure to obtain a phone number for Resident #1_x001A_s physician phone number resulted in a delay in medical services for Resident #1 and placed Resident #1 at risk of harm.,2,0,Substantiated,Not Substantiated, +PT120146,385161,NF,5/18/2012,"Evidence and interviews indicated facility failure to provide Resident #1 with a safe environment on 05/18/2012. RP2 (CNA) pushed Resident #1 in her/his ambulation device while Resident #1 ""straddled the gait belt"" and her/his feet dragged behind and underneath the ambulation device resulting in Resident #1 sustaining injury and unreasonable discomfort.",3,400,Substantiated,Substantiated,Neglect +OR0000940801,385161,NF,12/18/2014,"Evidence and interviews indicated facility failure to provide Resident #10 adequate care and services related to incontinence care. Facility failure to provide adequate incontinence care for Resident #10 resulting in Resident #10 sustaining unreasonable discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,600,Substantiated,Substantiated,Neglect +OR0000940802,385161,NF,12/18/2014,"Evidence and interviews indicated facility failure to provide adequate pressure sore care and services for Resident #10. Facility failure to provide adequate Resident #10 adequate pressure sore care and services resulting in Resident #10's Stage I coccyx ulcer deteriorating to a Stage III pressure ulcer with full thickness tissue loss is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000940803,385161,NF,12/18/2014,Evidence and interviews indicated facility failure to ensure timely medical care and assistance to provide for resident needs based on care plans for Resident #10 and other facility residents. This failure placed residents at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000940804,385161,NF,12/18/2014,Evidence and interviews indicated facility failure to provide a diabetic and soft diet for Resident #10. Facility failure to provide a therapeutic diet for Resident #10 placed the Resident at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000941800,385161,NF,12/23/2014,"Evidence and interviews indicate facility failure to ensure changes in Resident #11's medical condition were reported to Resident #11's physician and family. Resident #11 was left unresponsive for approximately five hours before emergency measures were initiated. Facility failure to ensure adequate care and services related to Resident #11's change in medical condition are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000941801,385161,NF,12/23/2014,Evidence and interviews indicated facility failure to provide Resident #11 adequate care and services related to nutrition and hydration. Federal penalty recommended relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000941802,385161,NF,12/23/2014,Evidence and interviews indicated facility failure to ensure nurses acted within professional standards of practice by responding timely to Resident #11's change in medical condition. Resident #11 was left unresponsive by facility staff for approximately five hours before emergency measures were identified. Facility failure to ensure timely medical treatment for Resident #11_x001A_s change in medical condition is a violation of resident rights is considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.,3,,Substantiated,Substantiated,Neglect +OR0000923301,385161,NF,9/23/2014,"Evidence and interviews failed to indicate facility failure to provide Resident #3 with adequate intervention care and services related to two falls Resident #3 sustained in September 2014. Facility failure to provide residents adequate incontinence care and services resulting in multiple occasions where residents were found sleeping in wet and soiled linens is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +OR0000923302,385161,NF,9/23/2014,"Evidence and interviews indicated facility failure to provide adequate care and services related to the timely administration of Resident #1 and Resident #2's pain medication, placing the residents at risk for unmet needs. Relevant portions of the complaint report are attached.",2,,Not Substantiated,Substantiated, +OR0000933500,385161,NF,11/14/2014,Evidence and interviews indicated facility failure to ensure adequate care and services related to infection control standards for residents. Federal penalty recommended relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000933501,385161,NF,11/14/2014,"Evidence and interviews indicated facility failure to provide adequate care and services for residents' including Resident #6, Resident #7, Resident #8 and Resident #9. Facility failure to ensure changes in residents' medical conditions were reported to resident's families and physician for Resident #6, Resident #7, Resident #8, and Resident #9 put all residents' at risk for extended delays in treatment, unaddressed declines in health and avoidable pain and discomfort. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000933502,385161,NF,11/14/2014,"Evidence and interviews indicated facility failed to follow physician orders for timely laboratory services, provision of TED hose, weekly weights and supplements and alternates provided when eating less than 50 percent of meals for residents including Resident #5 and Resident #9; these failures placed residents at risk for unmet needs. Federal penalty recommended relevant portions of the complaint report are attached.",3,,Not Substantiated,Substantiated, +OR0000933504,385161,NF,11/14/2014,"Evidence and interviews indicated facility failure to ensure sufficient nursing assistant staffing on four of four halls to provide for resident needs based on the plans of care. Facility staff #2, #4, #8, #10, #11, #19, #20 and #24 (CNAs) indicated staffing was an ongoing problem across all shifts with evening and night shift the most affected; the worst between October and December 2014. Staff #16 (licensed nurse) indicated there were only two staff working ""the floor"" on 1/16/2015 and further indicated shifts had been working short staffed for at least four to five months off and on. This facility failure placed residents at risk for unmet needs.",3,,Not Substantiated,Substantiated, +OR0000933505,385161,NF,11/14/2014,"Evidence and interviews indicated facility failure to ensure residents' changes in condition were identifi8ed and responded to in a timely fashion for residents including Resident #5, Resident #6, Resident #8, and Resident #9. Resident #8 experienced ongoing pain, vomiting, black stool and further decline in condition. Resident #9 experienced prolonged abdominal pain and further decline in condition. Federal penalty recommended relevant portions of complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000933506,385161,NF,11/14/2014,Evidence and interviews indicated facility failure to provide residents adequate care and services related to incontinence care supplies. Evidence and interviews indicated facility failure to provide residents the correct size of incontinent briefs and gowns used for infection control placing the residents at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000934100,385161,NF,11/14/2014,Resident #10 was admitted to the facility without a MRSA diagnosis. Resident #10 had multiple admissions to the hospital during her/his stay in the facility. Resident #10 was found to have a MRSA infection during her/his December 2014 hospitalization. Evidence and interviews indicated a resident with MSA was bathed in the facility shower room with proper precautions in place and sanitizing completed prior to other residents use. An infection control concern was found unrelated to Resident #10 and was cited. Relevant portions of the complaint report investigation are attached.,3,,Not Substantiated,Substantiated, +OR0000934102,385161,NF,11/14/2014,"Evidence and interviews indicated Resident #10 received pain medication as ordered by the physician. Resident #10 did not show signs of over sedation with the administration of medication. Resident #10 was seen at the hospital for changes in her/his medical condition unrelated to medication administration. Medication administration concerns were unsubstantiated for Resident #10, however, additional residents were reviewed with deficiencies found related to medication administration. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000934103,385161,NF,11/14/2014,"Evidence and interviews indicated facility failure to provide pressure-relieving devices arrange for a podiatry appointment, conduct consistent pressure ulcer assessments, follow physician_x001A_s orders for dressing changes and provide protein powder for Resident #10. Resident #10 was admitted to the facility with a Stage I coccyx ulcer that deteriorated to Stage III. Facility failure to provide adequate skin care for Resident #10 resulting in pressure sores worsening is violation of resident rights, considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000934104,385161,NF,11/14/2014,"Evidence and interviews indicated facility failure to provide Resident #10 adequate care and services related to incontinence supplies. Facility failure to provide adequate incontinence care for Resident #10 resulting in Resident #10 sustaining unreasonable discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached. Note: facility failure to provide Resident #10 adequate care and services related to incontinence care was also cited and substantiated in complaint report investigation OR0000940801.",2,,Substantiated,Substantiated,Neglect +OR0000940800,385161,NF,12/18/2014,"Evidence and interviews indicated facility failure to follow physician's orders for the provision of bowel care for Resident #10. Facility failure to provide adequate bowel care for Resident #10 resulting in Resident #10 sustaining a fecal impaction, requiring hospitalization is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +PT151884,385161,NF,7/2/2015,"Evidence and interviews indicated facility failure to assure Resident #1's safety related to circumstances on or about 7/2/2015 where Resident #1 left the facility via a sliding door in the dining room. Law enforcement were notified and they located Resident #1 in the surrounding community, uninjured, returning Resident #1 to the facility after she/he had been missing from the facility for a few hours.",2,,Not Substantiated,Substantiated, +OR0000973600,385161,NF,6/3/2015,"Evidence and interviews indicated facility failure to provide adequate care and services related to Resident #1's safety. Evidence and interviews indicated facility failure to implement care plan interventions (non-skid socks) for Resident #1 who sustained a fall with fracture. The facility failure to provide Resident #1 adequate care and safety services resulting in Resident #1 sustaining a fall requiring hospital treatment, is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +PT164684,385161,NF,2/17/2016,"Evidence and interviews indicated RP2/AP2 (licensed nurse) told Resident #1 to ""kiss my ass"" during a dispute between Resident #1 and RP2/AP2 on or about 2/17/2016.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +NW117677,385162,NF,4/17/2011,"On 4/17/2011 RP2 (CNA) was assisting Resident #1 in standing in a standing lift. Witness #2 said, RP2 approached Resident #1 and without verbalizing what she/he was doing, RP2 ""yanked"" Resident #1's pants down. Witness #2 said Resident #1 appeared frightened and angry after this occurred.",2,0,Not Substantiated,Substantiated, +NW117703,385162,NF,5/19/2011,"Evidence and interviews indicated RP2 spoke profanity in a loud voice while providing care assistance for Resident #1 and Resident #2 in their room. Witness #1 and witness #2 said Resident #1 and Resident #2 were visibly upset by what RP2 said. RP2 acknowledged the incident and attributed it to being ""stressed out.""",2,0,Not Substantiated,Substantiated, +OR0000711701,385162,NF,8/29/2011,Evidence and interviews indicated facility failed to ensure a safe medication system for Resident #1 resulting in Resident #1 sustaining an allergic reaction to medication requiring hospital treatment. Federal penalty recommended; relevant portions of the substantiated complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000696500,385162,NF,6/28/2011,Evidence and interviews indicated the facility failed to follow the care plan for Resident #1 resulting in Resident #1 sustaining a fractured shoulder. Relevant portions of the complaint survey report are attached; a federal penalty was recommended.,3,0,Substantiated,Substantiated,Neglect +NW129261,385162,NF,12/27/2011,"On 12/27/2011 RP2 (CNA) grabbed Resident #1 by the ankles, swung her/his legs to pivot Resident #1_x001A_s body to the edge of the bed. RP2 did not provide cues to Resident #1 when attempting to assist Resident #1 from her/his bed to a wheelchair. Resident #1 said RP2 rough handled her/him and treated her/him like Resident #1 _x001A_did not matter._x001A_",2,0,Not Substantiated,Substantiated,Neglect +OR0000782000,385162,NF,9/6/2012,Evidence and interviews indicated facility failure to provide Resident #1 adequate medication administration. Relevant portions of the complaint report investigation are attached.,3,400,Substantiated,Substantiated,Neglect +OR0000782001,385162,NF,9/6/2012,Evidence and interviews indicated facility failure to provide Resident #1 ongoing wound/edema assessments and response to treatment as care planned. Relevant portions of the investigation complaint report are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000782002,385162,NF,9/6/2012,Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services regarding a urinary tract infection. Relevant portions of the investigation complaint report are attached.,2,0,Not Substantiated,Substantiated, +OR0000797001,385162,NF,12/7/2012,Based on interviews and record review it was determined the facility failed to notify Resident #1 and Resident #5's family members when there were significant changes in the residents' physical conditions. These failures placed the residents at risk of not receiving psychosocial support and medical treatment. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +OR0000810800,385162,NF,2/11/2013,Evidence and interviews failed to indicate facility failure to provide Resident #2 care and services regarding Resident #2's hip replacement. Evidence and interviews indicated facility failure to thoroughly investigate an injury of unknown cause regarding Resident #2. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +NW133196,385162,NF,1/29/2013,"Resident #1 had a stomach issue on 01/29/2013 and requested assistance from RP2 (CNA). Resident #1 did not receive toileting assistance from RP2 nor was Resident #1 assessed or assisted by licensed staff. Witness #1 (licensed staff) assisted Resident #1 the morning of 01/29/2013. Resident #1 was observed by staff to have dried feces on bed linen, clothing and flooring. The facility failure to provide Resident #1 adequate toileting assistance resulted in Resident #1 sustaining a loss of dignity. This failure is considered neglect of care and constitutes abuse.",2,0,Substantiated,Substantiated,Neglect +OR0000889700,385162,NF,4/10/2014,Evidence and interviews indicated facility failure to have physician orders for flushing Resident #1's PICC line (a central line catheter that is placed in a large vein toward the heart) and ensure the line was flushed. The facility failure to have physician orders for Resident #1's PICC line and ensure the line was flushed placed Resident #1 at risk for complications from the PICC line. Relevant portions of the complaint report investigation are attached.,3,250,Not Substantiated,Substantiated, +NW151564,385162,NF,4/18/2015,Evidence and interviews indicated RP2 (licensed nurse) administered 50 mg of an ordered medication to Resident #1 instead of the 25 mg prescription on 4/17/2015. Evidence and interviews indicated Resident #1 was asymptomatic as a result of RP2's medication error.,2,,Not Substantiated,Substantiated, +RB105693,385164,NF,11/10/2010,"RV was given a second dose of a anti-psychotic medication within an hour of the initial does of medication. Staff report RV vomited and spit out the first does of medication. Staff gave an injectable medication without an order for that delivery route for the medication. RV did not sustain notable harm, but was at risk for harm.",2,0,Not Substantiated,Substantiated, +OR0000675803,385164,NF,3/14/2011,"Resident 1 was admitted with diagnoses including aspiration pneumonia. Resident 1's physician ordered an over the counter medication Prilosac, but staff failed to ensure the medication was ordered and given. Staff failed to maintain acceptable parameters for Resident 1's nutritional status. Resident 1 experienced a severe weight loss in less than one month. No documentation could be located to indicated the Registered Dietician had been notified of Resident 1' weight loss. No assessment could be located regarding Resident 1's continued weight loss. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000675804,385164,NF,3/14/2011,Resident 1 was admitted with diagnoses including aspiration pneumonia and dysphagia. Resident 1's assessment of 2/28/11 revealed Resident 1 required supervision eating. Review of Resident 1's meal monitoring indicated inconsistent monitoring of fluids. Resident 1 received IV fluids for dehydration. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +RB120943,385164,NF,8/1/2012,"The facility failed to protect multiple residents from inappropriate touch by RV1. Multiple witnesses (staff) had observed RV1 touch multiple residents including, but not limited to RV3 and RV4. Witnesses (staff) reported RV1 would place self in such manner as to observe other residents disrobe including, but not limited to RV5. The facility failed to reassess and or care plan interventions to limit RV1's inappropriate behaviors. Additionally the facility failed to report RV1's behavior event of February 2012. Facility failures constitute abuse and an Oregon Administrative Rule violation.",3,400,Substantiated,Substantiated,Neglect +OR0000801101,385164,NF,1/2/2013,The resident was admitted to the facility on 7/25/2012 with multiple diagnoses. The facility failed to develop and or provide written policies and procedures to protect misappropriation of resident property at the time of the resident death. The resident's wedding band went missing. The resident did not have an admission inventory sheet listing the resident's valuables. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Substantiated,Substantiated,Financial abuse +RB132093,385164,NF,12/30/2012,"Neither RV are reliable historians. RV2 reported feeling safe and denies anything happened. RV1 denies any such behaviors. Staff reported RV2 seeks attention, wheeled up to RV1 and RV1 placed his/her hand on RV2's leg. Witnesses reported RV1 was in line of sight and RV1 was not the aggressor this time. Staff provided intervention; moved RV1 to anew location. RV2 was observed holding hands with another resident the same afternoon. Staff failed to document/ care plan RV2's attentions seeking behavior. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +RB132682,385164,NF,3/9/2013,"RP2 became ""agitated"" with RV during RV's care due to RV's yelling and screaming. RP2 told RV if RV did not stop RP2 would put RP2's fingers in RV's mouth. RP2 placed a gloved finger in RV's mouth; pulling on RV's mouth. W2 observed and reported the incident. RP2 treated RV with disrespect and roughness. The facility suspended RP2 and terminated RP2's employment. RP2's actions constitute physical abuse. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated,Physical Abuse +RB132685,385164,NF,3/9/2013,"Staff knew RV1 was aggressive with staff. RV1's medication was changed, but staff failed to care plan for aggression and or move RV1. staff failed to have RV2 request staff interventions rather than RV2 approach RV1 resulting in RV1 and RV2 altercation. RV2's resident rights were violated and RV2 did have some headache for less than 24 hours. The facility failure to provide a safe environment constitutes abuse and an Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +RB145937,385164,NF,1/17/2014,RV1 and RV2's wheel chairs became entangled and RV1 pulled RV2's hair. RV1 and RV2's care plan address behaviors. Staff anticipate and promptly intervene by moving RV2 and redirecting RV1. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +RB146164,385164,NF,2/2/2014,RV1's care plan indicates RV is not to be alone in the dining room or alone in the solarium with other residents. W3 told RV1 to go ahead and wheel self to the solarium without ensuring RV1 would be alone or with staff supervision. W2 observed RV1's hand on RV2's leg/groin area. Neither RV was able to recall the incident. The facility failure to provide a safe environment resulted in a serious loss of resident rights/dignity. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0000874400,385164,NF,1/23/2014,"Resident 1 a long term resident with multiple diagnoses was care planned for extensive assistance for ADLs including a two person use of a stand lift. Resident MDS indicated resident cognitive impairment. On 8/14/2013 resident slid from the stand lift. W4 did not recall if the straps were in place, but W4 did not use a second person as care planned. Resident was not injured. W4 received counseling regarding following the care plan. On 1/9/2014 W5 turned to retrieve a wash cloth and resident rolled out of bed, but was not injured. Staff 5 received counseling. Staff failed to provide a safe environment resulting in resident falls and possibility for injury. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rules were violated.",2,,Not Substantiated,Substantiated, +OR0000875400,385164,NF,1/29/2014,"Resident 1 a long term resident with multiple diagnoses was care planned for extensive assistance for ADLs including a two person use of a stand lift. Resident MDS indicated resident cognitive impairment. On 8/14/2013 resident slid from the stand lift. W4 did not recall if the straps were in place, but W4 did not use a second person as care planned. Resident was not injured. W4 received counseling regarding following the care plan. On 1/9/2014 W5 turned to retrieve a wash cloth and resident rolled out of bed, but was not injured. Staff 5 received counseling. Staff failed to provide a safe environment resulting in resident falls and possibility for injury. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rules were violated.",2,,Not Substantiated,Substantiated, +RB146741,385164,NF,4/9/2014,"Both RV1 and RV2 have cognitive impairment and a history of behaviors. On 4/9/2014 staff intervened after RV1 rolled up to RV2, RV1 patted RV2's arm and RV2 yelled at RV1. staff failed to ensure RV1 did nor repeat the event resulting in RV1 and RV2 engaging in a physical altercation. Neither RV was injured, but potential for harm existed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000954300,385164,NF,3/11/2015,Resident was admitted January 2015 with diagnoses including Peripheral Vascular Disease (PVD). Periodic observation revealed resident's finger nails were clean and trimmed. Per documentation review oral care was inconsistent. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000954301,385164,NF,3/11/2015,Resident 1 was admitted to the facility January 2015 with diagnoses including dementia. The resident was identified by the facility as not interviewable. Staff 5 and W1 both report an inappropriate comment made to Resident 1 in which Staff 5 told the resident she did not have to take abuse from the resident. Staff 5 failed to report the events in resident's room to Staff 2 and Staff 5 said she should have accused herself from the room and reapproach the resident. Staff 2 was not aware of the event and would interview and re-educate Staff 5. The event was not timely investigated. Relevant portions of the survey are attached. Enforcement action ws recommended. Oregon Adminsktrative Rule violaiton occurred.,2,,Not Substantiated,Substantiated, +OR0000954303,385164,NF,3/11/2015,Resident 1 was admitted January 2015 with multiple diagnoses and physician ordered medication. The resident did not receive all physician ordered eye drops. Documentation does not indicate all eye drops were given as ordered or why the eye drops were omitted. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +RS152406,385164,NF,7/17/2015,"RP2 repeatedly told RV to shut up after becoming frustrated with RV. RV does not ""exactly"" remember what RP2 said, but said RP2 ""was not nice"". RP2 admitted an inappropriate outburst with RV. RP2 reported being extremely stressed; stated the facility had experienced three major staffing issues and RP2 had worked 160 hours of overtime between January and July. RP2 failed to treat RV with all due respect, but did not make derogatory remarks to RV. Evidence is not sufficient to support emotional abuse. The facility failed to provide sufficient staffing resulting in staff stress. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000658100,385165,NF,12/30/2010,The facility failed to ensure the resident had adequate devices as identified on the care plan to prevent accidents. Resident 1 care plan identified impaired mobility with care plan interventions to propel own wheel chair to build lower extremity strength. Resident 1 fell from the wheel chair during transport without use of a foot rest. Resident 1 sustained a laceration above the eye which required a trip to the ER for sutures. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000658300,385165,NF,1/3/2011,"Resident 2 was admitted September 2010 with diagnoses including dementia and agitation. On 12/24/10 at approximately 3:00 A.M. Resident 2 was placed in a Geri chair at the nurses station after repeatedly attempting to climb out of bed. Staff 12 applied a ""loose"" sheet around Resident 2 and tied a loose knot. Staff 12 did not complete an assessment on the use of the sheet. On 12/28/10 Staff 7 placed a sheet over the chair arms with out using an assessment or notifying a charge nurse. Many staff received further in-service regarding restraint use. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +GB134259A,385165,NF,8/23/2013,"Multiple witnesses spoke to staffing issues and call light response; especially around dinner time. Additional staff have been placed. W4 reviewed documentation and did not find any notes regarding use of a brace for RV. W9 will call W1 regarding use of the brace. RV's care plan failed to address use of the wrist brace. RV has no skin issues to indicate a chronic lack or poor incontinence care, but being left in urine soaked clothing is a significant dignity issue constituting abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +GB134446,385165,NF,9/15/2013,RV reported worry about proper care and now keeps a calendar of catheter changes. Witnesses and physician orders indicated RV was to have his/her Foley catheter changes every 30 days. Due to facility error regarding use of an electronic MAR and or staff failure RV's catheter was not changed at the 30 day interval in July 2013 and then in September it was not changed on the due date of 9/1/2013 until 9/12/2013. Staff were unable to remove the catheter ( per W7 it was stuck )on 9/12/2013; RV was sent to the ER for evaluation and treatment; and ultimately to a specialist over three hours away. RV sustained unnecessary worry and great potential for harm when RV's catheter was not changed as RV's physician ordered. Oregon Administrative Rule violations occurred.,2,400,Substantiated,Substantiated,Neglect +GB135358,385165,NF,12/8/2013,RV reported having two envelopes containing money. RV reported counting the money on 12/6/3013 and on a 12/8/2013 recount RV found money missing. RV reported the missing money. W2 conducted an investigation and replaced money RV reported as missing. The facility investigation was unable to determine when or how the money went missing. RV declined use of the facility safe. A lock box was installed in RV's bed side stand. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Financial abuse +OR0000907900,385165,NF,7/11/2014,"Resident 1 was a long term resident with multiple diagnoses. Resident's 1/15/2014 care plan required two person assist for ADLs and staff assist to reach one's destination. The resident was propelled while sitting in a wheel chair without foot rests, resident dropped his/her feet, fell out of the wheel chair and sustained a femur fracture. The AM of the event the resident had refused the foot rests. Staff 10 grabbed resident's clothing which slowed the resident down, but did not prevent the fall. The facility reviewed resident's care plan after the event. The facility failed to ensure resident care plan interventions were in place and or adequate to prevent the resident's fall relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000919100,385165,NF,9/3/2014,"Resident 2 was admitted in 2009 with multiple diagnoses. Resident 2 sustained a fall on 7/24/2014. the resident fell backward, struck his/her head and sustained an injury. Resident's family was not notified at the resident's request although there was not documentation in the resident's record. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +GB153504,385165,NF,11/9/2015,"RP2 failed to treat facility residents with care and dignity. Specifically RP2 was rough with RV1, RV2 and RV3. Witnesses and RVs report RP2 continued to provide care causing pain to RVs; and not stopping care/roughness at request of RV1 and RV3. RV2 reported RP2 hurt RV's head/neck and when RV2 asked RP2 not to watch a specific program involving guns RP2 responded ""I'll watch anything I want"". RP2's actions with RV1, RV2 and RV3 constitute abuse by neglect and physical abuse. The facility had been alerted to RP2's actions/behavior, but failed to adequately supervise and or promptly intervene resulting in continued abuse of residents. Oregon Administrative Rule violations occurred.",3,300,Substantiated,Substantiated,Physical Abuse +HB116144,385166,NF,1/12/2011,"RV is unable to give relevant information. RV was found in the facility back parking lot with out noted injury. RV wears a transponder which sets off the door exit alarms, but it did not set off the outside door exiting therapy. RV would have required someone to open the door into therapy in order to exit through the door exiting to the outside. Door receptors were moved in order to better receive signals. RV was placed on hourly checks.",2,0,Not Substantiated,Substantiated, +HB116975,385166,NF,4/9/2011,"RV reported taking rings off near his/her sink, entered the toilet as RP2 entered the room and when RV came out of the toilet the rings were gone. W2 reported RV did not have the rings on admission and were not noted on RV's personal inventory list. The rings may fallen down the sink since there was no plug for the drain. W1 reported bringing the rings after RV was admitted to the facility. A police report dated 6/2011 noted RP2 stating he/she had not taken RV's rings, had assisted RV in looking for the rings and did not know what happened to the rings. The origin of the rings disappearance remains unknown.",2,0,Not Substantiated,Substantiated, +HB117086,385166,NF,5/24/2011,"RV wears an alarm bracelet that should sound an alert if RV exits the building. On 5/24/11 RV exited the building after passing by W2 and leaving by the lobby door. The alarm failed, W2's back was to RV and RV left to wander about the parking lot. W4 left RV unsupervised for a few minutes believing all staff knew to monitor RV; W4 did not specifically ask other staff to watch RV. RV's care plan for safety was not followed. RV was at risk for harm.",2,0,Not Substantiated,Substantiated, +HB117308,385166,NF,6/25/2011,RV did not receive the full dose of RV's medication patch. The facility failed to order the 100 mcg patch in a timely manner. RV received the other patch containing 25 mcg of medication. RV did not complain of pain or request additional medication for break through pain. The facility took action to help prevent a similar occurrence.,2,0,Not Substantiated,Substantiated, +HB117742,385166,NF,8/12/2011,RP2 assisted RV with a showered and placed RV in a wheel chair just outside RV's room door while RP2 straightened RV's room. RP2 failed to apply RV's hand mitt as care planned. RV scratched/scraped his/her face before RP2 was able to place the mitt when reminded by W2. RP2 was counseled regarding RV's hand mitt.,2,0,Not Substantiated,Substantiated, +HB118341A,385166,NF,11/1/2011,On or about 10/28/11 RP2(a CNA) applied a heat pack per RP3's (RN) instruction to RV's back. Facility policy states only licensed staff apply heat packs; not a CNA. RP2 failed to use good judgment in following RP3's instruction to apply the heat pack. Both RP2 and RP3 failed to remove the pack in a timely manner and RV sustained a first degree burn on RV's mid back. By 10/30/11 the burn was resolving without incident. Both RP2 and RP3 were counseled and further education was provided to all staff. The facility provided prompt intervention to prevent a similar incident.,2,0,Not Substantiated,Substantiated,Neglect +HB120683,385166,NF,6/2/2012,"RV's fingers were swelling as W3 recalled prior to RV's ring coming up missing. RV is unable to give any information. RV's finger showed bruising after the ring was missing. LEA was notified by W4, but LEA was unable to locate any suspects. The facility searched for the ring, but failed to take further action including reporting the missing ring. There is no evidence the facility provided a thorough investigation. An Oregon Administrative Rule was violated.",2,0,Substantiated,Substantiated,Financial abuse +HB120749,385166,NF,7/29/2012,"RP2 admitted failing to use a gait belt during a transfer with RV, reported RV's knee buckled and RV was ""gently"" lowered to the floor. W3 reported there would be no was to ""catch"" RV as RV was going down. W3 and W4 gave differing opinions as to RV's outcome had a gait belt been utilized. RV sustained slight swelling to his/her ankle. RV's care plan was up dated to include a two person transfer. The facility failure is a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +HB121515,385166,NF,11/1/2012,RP2 and RP3 provided RV transfer without a RN present. RV sustained a skin tear to RV's right cheek. RP2 and RP3 deny knowing about RV's care planned RN present during transfer. RP2 reported being new to the unit. RP3 reported he/she was in training at the time of the event. The facility failed to properly supervise staff and ensure RV's care plan was understood and followed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +HB121804,385166,NF,11/29/2012,RV has been a resident of the facility since 1/13/2012 and is care planned to use Geri sleeves due to RV's fragile skin. RV sustained two skin tears; one to the left shin on 5/22/2012 and one to left wrist on 10/22/2012. RV had the Geri sleeves in place on 10/22/2012. Multiple staff do not recall whether or not the sleeves were place prior to the day RV sustained a skin tear to the front forearm. W3 reported not seeing Geri sleeves on RV and the treatment book did not indicate an order fro using the sleeves. W3 reported no care plan was in RV's room. W2 reported the in room care plan did not show RV's need to wear the Geri sleeves. The facility failed to ensure RV's care plan reflected required care and or failed to ensure all staff were informed of the required care. The facility failure resulted in minor harm and constitutes abuse. The failure is an Oregon Administrative Rule violation.,2,0,Substantiated,Substantiated,Neglect +OR0000800100,385166,NF,12/26/2012,Resident 1 was admitted 2010 with multiple diagnoses and the 12/6/2012 care plan indicated fall risk. Interventions included transfers using a gait belt. Documentation of 12/17/2012 indicate the resident fell in the bathroom during a transfer with Staff 2. the resident sustained bruises to the right hand and complained of a sore bottom. Other resident falls were reviewed indicating staff not following resident care plan and or not knowing of the care plan the facility failed to thoroughly investigate all falls. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +HB133305,385166,NF,5/23/2013,"RV recalled lying in bed, reading his/her cell phone, falling out of bed and striking his/her head. RV reported the fall was his/her fault. W2 reported the facility received faxed orders containing RV's and another resident's orders. RV received anxiety medication every 4 to 6 hours instead of PRN or as needed. Evidence remains inconclusive if the medication resulted in RV's falling out of bed. An Oregon Administrative rule violation occurred.",2,,Not Substantiated,Substantiated, +HB133756,385166,NF,7/10/2013,"RP2 was very busy, had provided previous dressing changes, failed to read or comprehend dressing change orders and applied the previous ordered dressing change. Since there was a three day delay between dressing changes and noted wound change, RV's condition change and treatment were compromised. Evidence is insufficient to provide a direct link between the dressing change error and RV's change of condition. Keeping the dressing supplies in the resident's room likely compounded the error. RV received further treatment and the infection resolved. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +HB133626,385166,NF,6/27/2013,RV sustained a arm bruise of unknown origin. RV had refused to use the gait belt at times and multiple staff failed to notify the licensed staff of RV's refusal. RV's care plan was adjusted once licensed staff knew of RV's refusal. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +HB134033,385166,NF,8/6/2013,"RP2 responded to a cry for help, leaving RV on the bedside without an alarm or on skid socks or the bed in the lowest position. RP2 reported not turning on the alarm as it ""irritated"" RV or making RV get in bed as it agitated RV. RP2 returned within 5 minutes and found RV sitting on the floor. RV sustained a ""minor"" abrasion. RP2 failed to thoroughly follow RV's care plan. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000841800,385166,NF,7/29/2013,Resident 1 has involuntary arm movements. Full grab bars were placed on resident's bed placing resident at risk for harm. Resident sustained a arm fracture which may have occurred while striking his/her arm on the grab bars. Relevant portions of the survey are attached. Enforcement action was taken. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +HB133809,385166,NF,7/14/2013,RV1 has a history of behaviors and the care plan indicated supervision when RV1 is around other residents. W1 observed RV1 wheel up to RV2 and strike RV2. There were no care givers in the vicinity when the event occurred. RV1 care plan was not followed. A Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +HB134231,385166,NF,8/26/2013,RV1 struck RV2 causing a superficial scratch to RV2's right cheek. Facility staff failed to follow RV1's care plan intervention of supervising RV around other residents. RV1 has a history of behaviors including hitting and scratching. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Neglect +HB134589,385166,NF,10/2/2013,"A transcription error resulted in staff giving medication other than what the physician ordered. RV sustained changed of condition and received treatment. Staff informed the resident's family, physician,etc. The facility provided in-service training to all staff.",2,,Not Substantiated,Substantiated,Neglect +HB134317,385166,NF,9/4/2013,"While staff provided some care plan interventions to address RV's behaviors, the behavior continued with RV1 grabbing RV2 and RV3. RV2 sustained a minor redness and swelling of his/her wrist. The facility failed to thoroughly reassess and promptly provided progressive intervention to prevent resident to resident physical altercation. The facility failure constitutes neglect of care. An Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +OR0000860901,385166,NF,10/31/2013,"Resident 1 was admitted with diagnoses including a fractured hip and dementia. W1 stated resident required a two person transfer and use of a gait belt, but not all transfers were completed by two staff and use of the gait belt. Staff failed to follow resident care plan at all times. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +HB147237,385166,NF,5/29/2014,"RV reported complaint of pain in both hands to W6. W6 observed bruises to RV's hand/finger area and reported to W5. RP2 reported assisting RV to bed on 5/28/2014, denied observing RV hitting his/'her hands, but reported RV was waving his/her hands. RP2 reported noticing bruises to RV's hands and reported this to W5, but W5 denied RP2 reported bruises to them. W5 reported W6 reported RV's bruising the evening of 5/28/2014. W9 was called in as a translator and RV stated to W9 ""someone did this to me"" and RV described twisting of his/her fingers. RV pointed to RP2 as RP2 entered RV's room and told W9 that RP2 was the one who did this. Preponderance of evidence finds RV a credible reporter. RP2's action of twisting RV's hands causing bruises constitutes physical abuse. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Physical Abuse +OR0000901100,385166,NF,6/3/2014,"Resident 1 was a long time resident with multiple diagnoses. Resident care plan dated 6/3/2014 indicated a high fall risk with interventions including a low bed, nonskid socks and a pressure alarm. On 6/1/2014 the resident was found on his/her room floor with a small bruise to the right elbow. The resident's alarm was not in place and or turned on. Staff 3 could not recall if he/she had checked resident's alarm prior to the resident fall. Reviewer notes alarms in and of themselves do not prevent all falls. Relevant survey pages are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HB148248,385166,NF,8/25/2014,"RV requires a Hoyer lift transfer and repositioning every two hours due to skin at risk. RP2 usually repositioned RV by 7:00 A.M.; arrived at work at 6:30 A.M. RP2 was training new staff and failed to reposition RV with in two hours. RV sustained some skin break down, but evidence is insufficient to say exactly when the break down occurred. RP2 has a history of exemplary care. Staff assessed RV, notified the physician/family and began treatment. RP2 receive further instruction. Given RP2's additional duties, other staff including licensed nurses could have provided care to reposition RV. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +HB150038,385166,NF,1/26/2015,"RV reported RP2 pushed RV in RV's wheel chair into RV's room resulting in RV's leg bumping the foot board of RV's bed. RV reported believing it was an accident. RV reported a bruise showed the next day. RP2 recalled the day, but not a situation as RV described. RV denied telling RP2 it hurt. W1 denied RV reported an event to them. W2 stated RV reported to them on 1/12/15, but not on 1/8/15 after RV's appointment when W2 spoke with RV. RV was inconsistent in stating when the leg bump occurred. No evidence of bruising was found.",2,,Not Substantiated,Substantiated, +HB150308B,385166,NF,2/19/2015,"RV was to begin a medication on 02/11/2015 and receive the medication for 7 days. W2 reported giving RV medication from another resident per W4's instruction as RV's prescription was not properly given to the pharmacy. W2 reported giving RV the other resident's medication for 4 days until RV's medication came in. W1 reported obtaining a new physician order on February 16, 2015 believing RV had not received any medication, the new order was filled and RV received medication for another 7 days for a total of 11 days. Staff did not know why the first prescription order did not come from the pharmacy. RV did not sustain known harm, but potential for harm existed when the resident received additional medication doses not ordered by RV's physician. The facility failed to maintain a safe medication system. Oregon Administrative Rule violations occurred.",3,200,Not Substantiated,Substantiated, +HB152613,385166,NF,8/27/2015,"RP2 had previously observed RV walking, had the wheel chair behind RV, failed to maintain contact using a gait belt. RV fell side was into the tub. RP2 used poor judgment and readily admitted his/her error. RP2 was counseled to always follow the care plan and or gain direction from licensed nurse. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HB153203,385166,NF,10/19/2015,"Neither RV1 or RV2 were able to contribute any information. Staff heard yelling near the nurses station and found RV1 on the floor with RV2 standing near a table pushed about 3 feet from the usual position. It is possible RV2 pushed the table into RV1. RV1 did not sustain notable injury. Interview indicates staff relied on word of mouth for resident plan of care as some staff do not have access to the resident electronic care plan and or are not aware of updated care plans. There is no policy to periodically check resident care plans. RV2's behaviors were not always assessed, care planned and interventions implement to address these behaviors resulting in resident to resident altercations. Residents were at risk for further harm. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0001014700,385166,NF,10/12/2015,"Resident 1 was admitted 2013 with diagnoses including general muscle weakness and anxiety. Resident care plan date 5/17/2013 indicated the resident was a two person assist with repositioning and turning in bed. MDS date 10/14/2015 indicated extreme two person assist with be mobility. On 10/9/2015 at 9:15 P.M. the resident fell to the floor, sustained bruises, laceration and a fractured left elbow. The resident's air mattress was not full prior to the resident falling. Staff 3 had a hand on the resident while Staff 4 stepped away to get Staff 5, but due to the mattress the resident rolled away and onto the floor. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.",3,,Substantiated,Substantiated,Neglect +HB154049,385166,NF,12/23/2015,"RV2 pushed a chair into the shin of RV1 causing an abrasion. RV2 has a history of aggressive behaviors and pushing furniture around. RV2 and RV3 were in a physical altercation using warm coffee and bowls. RV3 warned RV2 to stay away, RV3 threw coffee on RV2 and RV2 threw bowls at RV3 hitting RV3's hand causing a bruise. There is a history of a prior event of RV2 pushing a table into RV3 causing RV3 to fall. The facility failed to provide adequate monitoring, supervision and or staffing to prevent negative injury altercation between RV2; and RV1 and RV3. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",2,200,Substantiated,Substantiated,Neglect +ES105786,385167,NF,12/3/2010,"RP3 retuned RV to the room after therapy, connected the oxygen tubing to the concentrator and left the room. RP3 failed to ensure the oxygen was flowing to RV before leaving the room. RP2 was summoned to the room, turned on RV's portable oxygen tank and failed to ensure which piece of equipment the oxygen tubing was connected to. RP2 left the room and failed to ensure oxygen was flowing to RV. W3 again contacted RP2 who returned and made sure the oxygen was appropriately attached and flowing to RV. RV did not sustain notable negative effects, but was at risk for harm. RP2 and RP3 received further instruction to double check oxygen service.",2,0,Not Substantiated,Substantiated, +ES117826,385167,NF,7/26/2011,"W6's notes reveal RV sustaining no injury falls on 5/11 and 5/14/11 after sliding out of his/her wheel chair. RV's nursing notes show various falls from RV's wheel chair prior to the 5/11, 5/14 and 7/26/11 falls indicated in W6's notes. W6 and the nursing staff failed to adequately care plan RV's on going falls and failed to provide progressive interventions to prevent further falls. RV's fall/slide from his/her wheel chair during van transport may have been preventable had all of RV's falls been fully assessed and care planned. RV sustained minor injury from the fall/slide from his/her wheel chair.",2,0,Not Substantiated,Substantiated, +OR0000760000,385167,NF,5/3/2012,"Staff 4 (RP2) gave Resident 2 a PRN medication for agitation without providing care plan intervention first. Resident 2 did not show signs or symptoms of distress and calmed down. RP2 did not consult the licensed nurse prior to using the Ativan and ""forged"" the licensed nurse's initials on Resident 2's MAR. RP2's employment was terminated and appropriate agencies were notified.",2,0,Not Substantiated,Substantiated, +OR0000765300,385167,NF,6/6/2012,"Multiple staff gave Resident 1 the incorrect Sinemet dosage for a period of hours/days. Multiple staff gave prefilled syringe medication that was filled by another licensed nurse; not by the pharmacy. Multiple staff failed to check the MAR order for Sinemet against the physician order. Resident 1 received more Sinemet than was ordered, sustained a negative outcome and was sent to the hospital. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure and negative resident outcome is abuse and represents an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +ES121044A,385167,NF,8/16/2012,"The complainant voiced multiple concerns regarding RV1's care. Witnesses reported RV1 was wet not assisted with changing his/her ""pampers"" in a timely manner. W3 reported instructing RP2 to assist RV1. W4 changed RV1. W4 reported RV1 was upset. RP2 failed to respond to the investigator. Preponderance of evidence supports RP2's failure to assist RV1 with timely incontinence care. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +ES121044B,385167,NF,8/16/2012,RP2 failed to give RV2 his/her suppository in a timely manner. W3 gave the suppository later in the morning. RP2 failed to respond to the investigator. RV2 did not sustain any harmful effects by receiving the suppository later in the day. The facility failure represents an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +ES121414,385167,NF,10/17/2012,"Staff failed to change RV's dressing in timely manner. RV refused a shower at times, but the facility failed to document the refusal or the failure to change the dressing in a timely manner. At the time of the event RV's dressing was to be change twice per week. RV dressing was found to contain maggots. RV's wound orders are back to changing the dressing every other day. RV received anxiety medication at the time of the incident. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000925700,385167,NF,10/9/2014,"Resident 59 was admitted 2013 with diagnoses including a stroke. Resident care plan dated 9/21/2014 identified a fall risk with care plan interventions to include a toilet seat riser with handles. On 10/5/2014 at 12:35 P.M, the resident was found on the floor in front of the toilet without noted injury and the toilet seat riser not in place. During the investigation observation found the resident in his/her recliner without a call light in reach and no tab alarm as care planned. Multiple staff reported the tab alarm was not used and should not be on the care plan. The resident care plan fall mat was not in the resident's room. The facility failed to ensure the resident's care plan was accurate and enforced placing the resident at risk for harm. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ES147209,385167,NF,5/1/2014,The complainant voiced multiple concerns as identified in the investigation report. Staff failed to have RV's oxygen equipment properly installed and read for transport resulting in RV missing transport to RV's appointment. RV didot receive adequate monitoring and peri care resulting in RV being soaked with urine for over two hours. Staff failed to ensure RV's medications were properly delivered at all times. The facility resulted in neglect of care which constitutes abuse. Staff received further in-service regarding RV's care. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +ES149336,385167,NF,11/20/2014,"RV interview found no concerns or complaints regarding RV's food. W1, 2,and 3 reported there is a concern whether a puree diet is appropriate for RV. W3 reported as long as there is an ordered for a puree diet it should be followed. W4 reported RV received pot pie with chunks of chicken on 11/20/14; not pureed or chopped. W4 stopped RV from eating the meal. There is no known event of RV choking or aspirating a piece of food that was too large. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000977102,385167,NF,6/23/2015,"Resident 1 was admitted May 2015 with diagnoses including stroke. The resident fell on 5/20 and 5/27/2015, received assessment, incident report with investigations or follow-up occurred and the resident care plan was adjusted for safety. The resident fell on 6/20 and 6/25/2015 and was assessed without noted injury, but there was not documented evidence the instigation occurred and possible new interventions developed. The facility failed to implement policy and procedure regarding fall incident. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred..",2,,Not Substantiated,Substantiated, +OR0000735600,385168,NF,12/21/2011,Evidence and interviews indicated facility failure to follow physical therapy recommendations and provide stand-by assistance for Resident #1 who was a fall risk. Resident #1 sustained a non-injury fall on 12/17/2011.,2,0,Not Substantiated,Substantiated, +OR0000748701,385168,NF,3/7/2012,Evidence and interviews indicated facility failure to ensure Resident #1's physician received timely notification of Resident #1's change in condition. Evidence and interviews indicated facility failure to ensure a timely response to Resident #1's change in condition on 04/25/2011.,2,0,Substantiated,Substantiated,Neglect +AL132087,385168,NF,10/8/2012,"Resident #1 had a medical condition that caused her/him an inability to use a bedside urinal without spilling the urine or her/himself. Resident #1's 10/2012 care plan did not reflect she/he should not use a bedside urinal. On the night of 10/8/2012 and the morning of 10/9/2012 Resident #1 asked RP2 (CNA) and RP3 (CNA) for bathroom assistance. RP2 and RP3 both asked Resident #1 to use a bedside urinal. Witness #2 indicated Resident #1 cried and indicated the CNA's had been ""mean"" toward her/him by insisting she/he use a bedpan. The facility failure to adequately care plan for Resident #1's care needs is considered neglect of care.",2,0,Substantiated,Substantiated,Neglect +OR0000829801,385168,NF,5/14/2013,"Evidence and interviews indicated facility failure to care plan, follow physician_x001A_s orders and monitor gastric residual volumes for Resident #1 and Resident #2. The facility failure placed Resident #1 and Resident #2 at risk for aspiration pneumonia, diarrhea, vomiting, dehydration and metabolic abnormalities. Relevant portions of the complaint report investigation are attached.",3,,Not Substantiated,Substantiated, +OR0000829800,385168,NF,5/14/2013,"Evidence and interviews indicated facility failure to obtain physician orders for care and treatment and failure to develop a temporary care plan for Resident #1 who had a neck stoma (opening in the body), surgical incisions and a urinary catheter. The failure placed Resident #1 at risk for not receiving appropriate care and services. Relevant portions of the complaint report investigation are attached.",3,750,Not Substantiated,Substantiated, +AL132747C,385168,NF,12/8/2012,"Evidence and interviews indicated facility failure to provide Resident #1 with timely call light assistance resulting in Resident #1 sustaining an incidence of incontinence and expressing she/he was ""embarrassed.""",2,,Not Substantiated,Substantiated, +OR0000856500,385168,NF,10/3/2013,Evidence and interviews indicated facility failure to provide the necessary care and services related to Resident #1's tracheostomy care placing Resident #1 at risk for respiratory complications.,2,,Substantiated,Substantiated, +AL151650,385168,NF,9/10/2014,"Evidence and interviews indicated facility failure to protect Resident #1 from RP2 (licensed nurse) rough treatment of Resident #1 on or about 9/10/2014. RP2 was providing care for Resident #1 in response to Resident #1's request for toileting assistance. While RP2 was assisting Resident #1, RP2 grabbed Resident #1's left hand and pushed it to her/his chest, resulting in Resident #1 sustaining a skin tear on the top of her/his left hand. The facility failure to protect Resident #1 from rough treatment by RP2, resulting in Resident #1 sustaining a skin tear is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +OR0000963000,385168,NF,4/15/2015,"Evidence and interviews failed to indicate facility failure to provide Resident #1 adequate care and services to prevent the development of pressure ulcers. Two additional residents were reviewed for pressure ulcers and evidence and interviews indicated facility failure to investigate new skin issues for Resident #2 and Resident #3 relevant to pressure ulcers. This failure placed Resident #2 and Resident #3 at risk of re-occurrence of pressure ulcers. In addition, evidence and interviews indicated facility failure to implement interventions to prevent the development of pressure ulcers for Resident #2. The facility failure to adequately monitor Resident #2 and Resident #3_x001A_s skin issues, resulting in Resident #2 developing pressure ulcers, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +AL151896,385168,NF,8/26/2014,"Evidence and interviews indicated Resident #1 was served a hot beverage, which she/he spilled on her/his lap sustaining full thickness burns to her/his left and right inner thighs. According to witness #3 (facility staff) the hot water came from a coffee making machine leased from a vending contractor. Witness #3 said the temperature of the hot water was unknown. The Facility failed to provide a safe environment for Resident #1 resulting in Resident #1 sustaining burns and unreasonable discomfort, is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000991100,385168,NF,8/10/2015,"Evidence and interviews indicated facility failure to adequately monitor Resident #1's post-operative incision. In addition, evidence and interviews indicated facility failure to notify Resident #1's interested family member regarding a change in Resident #1's post-operative incision. The Facility failure to adequately monitor Resident #1's post-operative incision resulting in Resident #1's medical condition worsening, is a violation of resident rights, is considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,450,Substantiated,Substantiated,Neglect +AL153842B,385168,NF,12/1/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from rough treatment by RP2 (CNA) who provided rough treatment when providing Resident #1 care assistance with toileting on or about 11/27/2015. The facility failure to ensure RP2 was adequately trained resulting in Resident #1 sustaining discomfort with RP2's rough treatment, is a violation of resident rights, and constitutes physical abuse.",2,,Substantiated,Substantiated,Physical Abuse +AL153333A,385168,NF,9/29/2015,"Evidence and interviews were inconclusive regarding facility failure to protect Resident #1 from the theft of approximately $250 on or about 9/29/2015. However, evidence and interviews indicated facility failure to provide facility residents lockable storage in individual resident rooms as required by Oregon Administrative Rules.",2,,Inconclusive,Substantiated, +AL153333B,385168,NF,9/29/2015,Evidence and interviews indicated facility failure to report the potential or suspected financial exploitation of Resident #1 as reported to facility staff by Resident #1 and witness #7 on or about September 2015.,2,,Not Substantiated,Substantiated, +OR0000661300,385171,NF,1/12/2011,"On 1/9/11 Resident 1 was transferred with a sit to stand lift without use of a safety strap, Resident 1 let go of the hand grip, slid to the floor and sustained a ri8ght humeral fracture. Staff monitored Resident 1 and Resident 1 was sent to the hospital on 1/12/11 as Resident 1's condition deteriorated. Resident 1 sustained secondary blood loss due to Coumadin at the time of the injury. Staff 1 reported Resident 1 requested the safety strap not be used as Resident 1 complained of a ""tummy hurt"". Staff 1 should have sought licensed staff for further direction when Resident 1 refused to use the safety strap. Relevant portions of the survey are attached. A civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +MM120403,385171,NF,6/23/2012,"Staff failed to adequately address and care plan RVs' behaviors. In particular, staff failed to address RV's agitation and behaviors surrounding showering, kicking and hitting. Staff voiced many concerns including RP2 hitting RV's hand, but RV had no sign of trauma and RP2 denies striking RV. RP2 reported placing RV's hand by RV's side when RV pinched. The facility failed to care plan RV's behavior and or give staff direction to mitigate the behavior. Evidence fails to support rough handling, but does support a facility Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +MM133729,385171,NF,7/4/2013,"RV was known to attempt elopement, but RV's care plan did not address the risk. The facility procedure of placing pictures of residents at elopement risk was not followed for RV. RV did elope to the facility parking lot without known negative effect. RV was at risk for harm. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +MM135296,385171,NF,11/30/2013,RV was lowered to the floor during a one person transfer. RV 's care plan indicated a two person transfer. The facility found RV's boot slipped which caused the event. Using two people may or may not have prevented lowering RV to the floor. RV sustained some shoulder strain. RP2 received further in-service and RV's care plan was changed to boot removal prior to transfer. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +MM146886,385171,NF,4/17/2014,"RV's rings were loose per witness and staff, but staff failed to offer to lock the rings in the safe or ask family to take the rings home. RV's rings went missing between 4/17 and 4/18/2014. staff searched for the rings, but did not find them. The facility is looking to replace the rings. An in-service was held for staff on 4/22/2014 regarding identifying resident personal items. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000895900,385171,NF,5/9/2014,Resident 2 a long term resident with assessed aspiration risk received a cup of water from a visitor on 5/4/2014; coughed and vomited; and continued to cough for approximately 15 minutes. Staff failed to promptly notify resident family and physician of the event. Resident condition changed on 5/5/2014 and staff notified the physician and family. Relevant portions of the survey are attached. Enforcement was proposed and Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +MM149577,385171,NF,12/9/2014,"RV reported RP2 gave RV a ""hard time"" about everything; that RP2 ""yells"" at RV; that this has been going on; and RV gets upset. W2 (resident) reported RP2 ""yelled"" at RV and RP2 had yelled at W2 on a previous occasion, but W2 would not listen to RP2. W3 (resident) reported RP2 does not talk very nice to RV. W1 spoke with RV, other residents and felt ""confident"" the incident with RV occurred. W1 reported talking with RP2 in the past about the way RP2 comes across to residents. The preponderance of evidence support RP2 's emotional abuse of RV. The facility took appropriate action to protect the resident population by terminating RP2's employment and reporting the incident.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +OR0000993900,385171,NF,8/13/2015,"Resident 16 was admitted 2011 with diagnoses including dementia. The resident's 1/23/2015 Fall CAA identified a fall risk and indicated a need for one person assistance with transfers. The comprehensive care plan was up dated 5/20/2015 with regards to falls and interventions. On 8/11/2015 at 11:32 P.M. staff found the resident on the floor sitting against his/her bed. The resident sustained left hip injury. Hospice was notified and the resident received Roxanol. The resident was in extreme pain at 1:01 A.M., hospice was notified and Roxanol was administered. On 8/13/2015 the resident was too painful and resident's methadone was increased. The resident's care plan was not followed prior to the fall; resident's wheel chair was not left near the bed and the resident attempted a self transfer, fell and sustained injury. Various staff report the resident the wheel chair was 4 to 8 feet away. The resident continued to decline; unable to take food/fluids or be repositioned without being in extreme pain. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000922701,385172,NF,9/22/2014,Evidence and interviews indicated facility failure to timely notify Resident #2's interested family member regarding a change in Resident #2's medical condition placing Resident #2 at risk for lack of family member involvement in care. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001052002,385172,NF,1/20/2016,"Evidence and interviews indicated facility failure to adequately notify Resident #29's responsible party regarding a medical procedure Resident #29 underwent at the local hospital on or about 1/12/2016, placing Resident #29 at risk for being able to make an informed decision. In addition, evidence and interviews with an expanded investigation, indicated facility failure to promptly notify a physician regarding Resident #15's severe weight loss from 1/8 through 1/27/2016 placing Resident #15 at risk for being able to make an informed decision. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +JG145769,385177,NF,10/2/2012,Evidence and interviews indicated facility failed to provide adequate care for Resident #1 related to an incident where staff intended to place Resident #1 in a urine-soaked bed after returning to the facility from hospitalization. Emergency transport staff asked that Resident #1's bedding be changed prior to assisting the resident back to bed.,2,,Not Substantiated,Substantiated,Neglect +OR0000655500,385180,NF,12/21/2010,"Resident 1 was admitted on 12/17/10 with multiple diagnoses. On 12/18/10 at approximately 7:40 P.M. W2 gave Resident 1 medication intended for another resident. Resident 1's physician was notified of the error and orders were received including giving medication to reverse the effects of the narcotic should Resident 1 become sedated. Resident 1 was transferred at 6:15 A.M. when his/her respirations changed. the resident sustained the condition change at 5:50 A.M. and Resident 1's family was not notified of the multiple medication errors until after the Resident was transferred to the ER. W2 reported believing Resident 1 nodded when asking a resident's name. There were two new admissions (Resident 1 being one), but there were no pictures or ID bracelets for the two new residents. Room numbers were on the paper documents, but not outside the room doors. W2 received counseling and is no longer employed at the facility. Licensed staff and CNAs staff were also in-serviced regarding medication errors and not following the 5 rights for medication passes. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +MM116682,385180,NF,3/17/2011,"The facility failed to ensure a safe medication system and morphine belonging to RV disappeared. RP2 and other staff counted the remaining Morphine at shift change without verifying accurate measurement of the liquid left in the bottle. RP2 refused to take a drug test, but denied taking the Morphine. The facility replaced the missing Morphine, notified LEA and OSBN. The facility failure is an Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Financial abuse +RD117623,385181,NF,7/16/2011,"RV was admitted June 2011 with an end stage disease. RV was assessed and care planned as a fall risk. RV would attempt self transfer despite interventions and was very restless, kicking off covers most of the time. RP2 reported tucking covers around the bottom of the bed and tying the covers to the bed rail, but denies restraining RV's arms or legs. Witnesses indicated RV's movements were restricted to a certain extent. RP2 failed to assess and care plan for what would be considered a restraint. Evidence fails to support a negative effect to RV; only a risk for possible harm.",2,0,Not Substantiated,Substantiated, +RD149386,385181,NF,11/2/2014,RV requested medication for a headache. RP2 became side tracked while passing medication and failed to get back with RV's medication for approximately two hours. RV no longer required the medication when RP2 returned. RV was upset the medication was forgotten. The facility failed to provide a safe medication system resulting in delayed PRN medication pass. This delay resulted in potential harm. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ES117214,385182,NF,6/14/2011,Evidence and interviews indicated facility failure to adequately care plan to meet Resident #1's shaving assistance needs.,2,0,Not Substantiated,Substantiated, +ES121787A,385182,NF,11/7/2012,"Evidence and interviews indicated facility failed to provide adequate discharge information regarding Resident #1's pressure sores and related pressure sore treatment. Resident #1 was discharged from the facility to a community based care facility with no indication she/he had pressure sores, nor was there information regarding treatment of Resident #1's pressure sores. Facility failure to adequately discharge Resident #1 likely delayed ongoing care and treatment of her/his pressure sores.",2,0,Not Substantiated,Substantiated, +ES132342,385182,NF,12/24/2011,Evidence and interviews indicated RP2 (licensed nurse) provided Resident #1's wound care in an unsanitary way.,2,0,Not Substantiated,Substantiated, +ES117913B,385182,NF,9/1/2011,Evidence and interviews indicated facility failure to ensure Resident #1 received care and services that ensured Resident #1's right to care that was respectful and dignified.,2,0,Not Substantiated,Substantiated, +ES117913A,385182,NF,9/1/2011,Evidence and interviews indicated facility failed to ensure Resident #1 received adequate care and services related to toileting assistance resulting in Resident #1 experiencing a loss of dignity.,2,0,Not Substantiated,Substantiated,Neglect +OR0000875700,385182,NF,1/31/2014,"Evidence and interviews indicated facility failure to follow Resident #1's care plan and provide two-person assistance for bed mobility. Resident #1 fell out of her/his bed sustaining a right knee fracture and prolonged, increased pain. The facility failure to provide Resident #1 adequate care and services related to a fracture resulting in Resident #1 sustaining prolonged, increased pain are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000890000,385182,NF,4/11/2014,Resident #1 sustained a non-injury fall on 4/1/2014 when staff #3 and staff #4 provided transfer assistance. Evidence and interviews indicated facility failure to ensure Resident #1's in-room care plan was updated to reflect her/his latest transfer status.,2,,Not Substantiated,Substantiated, +ES149624A,385182,NF,12/16/2014,"Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to Resident #1's request for showering assistance. Resident #1 alerted witness #4 (licensed nurse) that she/he had not been receiving showering assistance for approximately a week prior to 12/16/2014. Resident #1 was scheduled to receive showering assistance on 12/16/2014 prior to a medical appointment on 12/17/2014. The facility failure to provide Resident #1 adequate showering assistance resulting in Resident #1 sustaining poor hygiene and embarrassment are violations of resident rights, are considered neglect of care and constitutes abuse.",2,350,Substantiated,Substantiated,Neglect +ES149624B,385182,NF,12/16/2014,Evidence and interviews indicated facility failure to assure Resident #1's rights related to an incident where facility staff argued with Resident #1 about her/his right to receive adequate care assistance on or about 12/16/2014. RP2 (CNA) and Resident #1 argued the night of 12/16/2014 about caregiving issues leaving Resident #1 upset and offended by conversation.,2,,Not Substantiated,Substantiated, +OR0000949401,385182,NF,2/17/2015,Evidence and interviews indicated facility failure to ensure Resident #1 was provided adequate thickened liquids and ensure adequate hydration. The facility failure to provide Resident #1 with adequate care and services related to monitoring Resident #1's aspiration precautions placed Resident #1 at risk for unmet hydration needs and dehydration. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +ES151025,385182,NF,4/21/2015,"Evidence and interviews indicated facility failure to ensure RP2 (licensed nurse) provided Resident #1 with a hot pack treatment to Resident #1's leg on 4/21/2015. RP2 microwaved the hot pack and applied it to Resident #1's left leg. RP2 said she/he was unaware facility protocol indicated hot packs should not be microwaved. The facility failure to ensure adequate care and services for Resident #1, resulting in Resident #1 sustaining unreasonable discomfort is a violation of resident rights, considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +ES153142D,385182,NF,10/12/2015,"Evidence and interviews indicated facility failure to provide a safe environment related to circumstances on or about 10/3/2015 when Resident #3 was using bathroom grab bars which were unsteady and improperly secured in the bathroom resulting in Resident #3 sustaining a fall with bruising. The Facility failure to provide a safe environment resulting in Resident #3 sustaining a fall with injury, is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000981700,385182,NF,7/22/2015,"Evidence and interviews indicated facility failure to adequately administer medications when failing to ensure medications prescribed to one resident were not administered to another resident (Resident #1). Resident #1 was incorrectly administered a significant amount of opioid narcotic pain medication. The facility failure to provide ensure Resident #1 was not administered medications she/he was prescribed, resulting in Resident #1 requiring hospitalization to reverse the effect of pain medication is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +BC129231,385183,NF,2/10/2012,Between 10-21-2011 and 1-30-2012 there were seven incidents of missing money from five residents; RV2 and RV3 reported two separate thefts of money and a wallet/purse. The facility replaced the money and lost items. Residents were given the option to use a lockable drawer. There were no known suspects. The facility failed to notify police until December 2011. The facility is exploring surveillance cameras. The theft of resident money and personal items is considered financial abuse and an Oregan Administrative Rule violation.,2,0,Substantiated,Substantiated,Financial abuse +OR0000796000,385183,NF,11/28/2012,"Resident 1 was admitted 10/18/2012 with multiple diagnoses including atrial fibrillation, CHF, PVD, diabetes and MRSA. The 10/18/2012 physician orders included medication for blood thinning at 2mg daily without orders for monitoring the blood levels of the medication. On 10/30/2012 a pharmacy note recommended monitoring the anticoagulation therapy, but no documentation was found to support the recommendation. Resident 1 discharged 11/2/2012. staff failed to ensure lab monitoring was completed for Resident 1. resident 1 was at risk for harm. Relevant portions of the survey area attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +BC132460,385183,NF,2/3/2013,Although the report indicated abrupt movement with care by RP2 further review does not find abuse. This reviewer found RV's care plan was not specific regarding transfer instructions for RV who had a recent hip fracture and surgery. At the time of the incident RV had not received therapy a evaluation and/or instruction for transfer. RP2 should have promptly sought further licensed nurse instruction when RV first complained at the beginning of the transfer. RP2 used poor judgment and provided less than stellar standard of care when attempting RV's transfer. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +BC132911,385183,NF,3/3/2013,Direct care giver was unable to pull up RV's care plan and RV was not provided Geri sleeves. RV sustained two small skin tears on two different dates. The system error was corrected when discovered. The facility failed to follow RV's care plan resulting in minor harm. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +BC146682,385183,NF,3/13/2014,The complainant reported a large leg bruise to RV's left leg was discovered on 3/11/2014; the day RV left the facility. W4 and 5 noticed a large reddish purple bruise to RV's leg while assisting RV with discharge from the facility. Witnesses deny observing a bruise earlier. RV receives medication that could increase the chance for bruising. W3 was not sure an incident report was required since RV was leaving the facility. There was a licensed nurse skin assessment. The facility failed to thoroughly investigated eh bruise of unknown origin and failed to report RV's injury. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000957402,385183,NF,3/20/2015,Resident 1 was admitted January 2015 with diagnoses including renal disease. On 2/26/2015 the resident was sustained a change of condition while at dialysis and was transferred to the hospital. Neither W1 or W2 was notified of the resident's transfer and hospitalization by the facility. The resident's rights was violated when the resident's emergency contacts were not notified of the resident's change of condition. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000649300,385185,NF,11/19/2010,A facility incident report dated 11/19/2010 indicated Resident #1 was trying to use a bed-side commode and fell. A bed pressure alarm and Resident #1_x001A_s tab alarm were not activated at the time of the fall. Resident #1 sustained a skin tear to her/his head. Staff #6 (CNA) said she/he had not attached the alarms. Staff #6 said the incident occurred on her/his second or third day on the job. Relevant portions of the survey report are attached.,2,0,Substantiated,Substantiated,Neglect +ES116028,385185,NF,12/30/2010,"December 14, 2010 documentation indicated Resident #1 had increased agitation with aggressive behaviors. Resident #1 had assaulted other residents. Resident #1_x001A_s care plan dated December 21, 2010 specified Resident #1 was to have one-on-one CNA staffing during days and evenings. Resident #2 had a history of wandering and behaviors. On December 30, 2010 at 7:30 am Resident #2 was slapped twice when Resident #2 approached Resident #1 and grabbed Resident #1_x001A_s arm. Resident #1 did not have a one-on-one caregiver assisting until 9 am on December 30, 2010.",2,0,Not Substantiated,Substantiated, +ES116103,385185,NF,1/6/2010,"RP2 (licensed nurse) said she/he received a verbal order from witness #1 for a heart medication for Resident #1. Resident #1 did not have a physician order for heart medication. Resident #1 was administered heart medication from December 26, 2010 through January 3, 2011.",3,250,Not Substantiated,Substantiated, +ES116227,385185,NF,1/27/2011,"Facility documentation specified Resident #1 required bathing assistance, weekly toenail cutting, hand washing after toileting and fingernail checking for cleanliness. Bathing records indicated Resident #1 received bathing assistance five times in December 2010 and twice during January 2011. Facility failed to provide Resident #1 adequate hygiene.",2,300,Not Substantiated,Substantiated,Neglect +OR0000690600,385185,NF,5/25/2011,Based on evidence and interviews it was determined RP2 failed to ensure fall interventions were in place for Resident #1 on 5/24/2011; Resident #1 sustained skin tears on the left arm. Relevant portions of the survey report are attached.,2,0,Not Substantiated,Substantiated,Neglect +OR0000704600,385185,NF,8/3/2011,Evidence and interviews indicated facility failed to provide adequate care and services to prevent Resident #2 from sustaining a right leg skin laceration. Relevant portions of the complaint report are attached; federal penalty recommended.,3,0,Substantiated,Substantiated,Neglect +ES117684,385185,NF,8/7/2011,"On or about 8/7/2011 RP2 and RP3 assisted Resident #1 onto a bed pan for toileting. RP2 went on break and RP3 was called away to assist with another resident. Resident #1 said she/he waited for more than 30 minutes, yelling and pushing the call light for assistance. Resident #1 said she was ""very uncomfortable"" from the bed pan and ultimately another resident assisted Resident #1 in getting off from the bed pan.",2,0,Substantiated,Substantiated,Neglect +OR0000717102,385185,NF,9/22/2011,Evidence and interviews indicated the facility failed to ensure physician orders were accurately followed for Resident #1 and Resident #4.,2,0,Not Substantiated,Substantiated, +OR0000718200,385185,NF,9/29/2011,Evidence and interviews indicated facility failed to ensure Resident #1 and Resident #4 were administered medication as ordered.,2,0,Not Substantiated,Substantiated, +OR0000732700,385185,NF,12/5/2011,Resident #1 was hospitalized in November 2011. Staff #2 said Resident #1_x001A_s bed was available when Resident #1 was ready to be discharged back to the facility on 11/14/2011. On 11/16/2011 the facility provided a Notice of Denial of Readmission/Return to Resident #1. The facility denied re-admission to the resident for a total of 29 days. Resident #1 was discharged from the hospital to a different facility on 12/12/2011.,4,7250,Not Substantiated,Substantiated, +ES129372,385185,NF,2/27/2012,"Evidence and interviews indicated facility failure to protect Resident #1, Resident #2 and Resident #3 from the financial exploitation of personal possessions and money by an unknown individual (RP99).",3,400,Substantiated,Substantiated,Financial abuse +OR0000756700,385185,NF,4/16/2012,Evidence and interviews indicated facility failure to complete and transmit Minimum Data Set (MDS) assessments for Resident #1 and Resident #2. Relevant portions of the complaint report are attached.,2,0,Not Substantiated,Substantiated, +OR0000756701,385185,NF,4/16/2012,Evidence and interviews indicated facility failure to assess the use of Resident #2's Foley catheter and failure to remove the catheter for a voiding trial prior to an urologist appointment. Relevant portions of the complaint report are attached.,2,350,Not Substantiated,Substantiated, +ES121161,385185,NF,9/24/2012,Evidence and interviews indicated facility failure to protect Resident #1 from the theft of money.,3,400,Substantiated,Substantiated,Financial abuse +ES118691,385185,NF,11/1/2011,Evidence and interviews indicated facility staff treated Resident #1_x001A_s skin condition with an over the counter lotion treatment without a physician order. Facility staff failed to communicate information regarding Resident #1_x001A_s skin issue to licensed staff and information was not integrated into Resident #1's care plan.,2,0,Not Substantiated,Substantiated, +OR0000825800,385185,NF,4/25/2013,"Evidence and interviews indicated facility failure to provide adequate care and services related to Resident #1's 04/20/2013 fall. Resident #1 sustained injuries requiring hospital treatment. This failure is considered neglect of care and constitutes abuse. Relevant portions of the complaint report survey are attached, federal penalty recommended.",3,,Substantiated,Substantiated,Neglect +OR0000833800,385185,NF,6/7/2013,The facility failed to ensure respiration parameters were consistently documented for the use of Norco (Narcotic pain medication) for Resident #2. The facility failed to ensure blood pressure parameters were consistently documented Resident #2 for the use of blood pressure medication. This failure put Resident #2 at risk for inaccurate medication administration. Relevant portions of the complaint report investigation are attached.,3,250,Not Substantiated,Substantiated, +OR0000845502,385185,NF,8/13/2013,"Based on evidence and interviews it was determined the facility failed to appropriately assess and document the effectiveness of PRN (as needed) pain medications for Resident #1. The facility failure to adequately assess and document the effectiveness of Resident #1's PRN pain medication resulting in Resident #1 sustaining ongoing, unassessed pain are violations of resident rights, are considered neglect of care and constitute abuse. Relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000867500,385185,NF,12/26/2013,Evidence and interviews indicated facility failure to implement policies and procedures regarding investigation and protection of residents and reporting allegations of abuse and/or neglect for Resident #1 and Resident #3. These failures placed Resident #1 and Resident #3 at risk for continued incidents of abuse and Resident #1 was at risk of injury from neglect of care. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000872100,385185,NF,1/10/2014,"Based on evidence and interviews it was determined the facility failed to ensure professional standards of practice were met for reporting abuse and protecting residents, following care planned interventions, reporting incidents and initiating alert charting, assessing and notifying the physician of new onset of pain for Resident #1. Resident #1 was at risk for continued incidents of abuse, injuries and/or complications from a change in condition. + + + +In addition, based on evidence and interviews it was determined the facility failed to initiate alert charting, assess and notify the physician regarding new onset of rib pain for Resident #1. Resident #1 was at risk for complications related to her/his change of condition. The facility failure to timely assess Resident #1_x001A_s change of condition placed resident at risk for complications related to the change and resulting in Resident #1 sustaining unreasonable discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,500,Substantiated,Substantiated,Neglect +ES145840,385185,NF,1/22/2014,"Evidence and interviews indicated facility failed to ensure Resident #1 had adequate hygiene care on the evening of 01/21/2014. Facility failure to ensure Resident #1 received adequate hygiene care resulted in Resident #1 having feces in her/his pubic area, sustaining burning, and itching. The facility failure to provide Resident #1 with adequate hygiene care resulting in Resident #1 sustaining discomfort are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000887501,385185,NF,4/1/2014,Evidence and interviews indicated facility failure to administer Resident #1's antidepressant medication as ordered placing Resident #1 at risk of receiving unnecessary dose(s) of medication. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +ES147708,385185,NF,7/11/2014,"Based on evidence and interviews it was determined the facility failed to provide Resident #1 timely PRN (as needed) narcotic pain medication. The facility failure to timely administer Resident #1_x001A_s narcotic pain medication, resulting in Resident #1 sustaining discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,300,Substantiated,Substantiated,Neglect +OR0000908100,385185,NF,7/14/2014,Evidence and interviews indicated facility failure to update and revise Resident #4's care plan to identify a health issue and implement staff interventions regarding the need for a cool environment. Evidence and interviews indicated facility failure to clarity and follow up on a physician's order for an air-conditioned environment and failure to implement a physician's order for a cooling vest for Resident #4. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +ES148889,385185,NF,10/10/2014,"Evidence and interviews indicated facility failure to ensure adequate care planning and protect Resident #1 from mental abuse related to her/his care assistance needs. The facility failure to protect Resident #1 from mental abuse while receiving care assistance are violations of resident rights, are considered mental abuse and constitute abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +ES148704B,385185,NF,9/1/2014,"Evidence and interviews indicated facility failure to ensure adequate care planning for Resident #1 related to fall risks. On 9/13/2014, facility staff sent a fax to Resident #1's physician to notify her/him of a fall and request a fall mat. The fax failed to transmit properly to Resident #1's physician and there was no care plan update to reflect an order for a fall mat.",2,,Not Substantiated,Substantiated, +ES148704C,385185,NF,9/1/2014,An Adult Protective Services investigator observed Resident #1 seated on a commode next to her/his bed on 9/29/2014. Resident #1 was in view sitting on a commode to anyone passing by her/his room as the privacy curtain was not drawn and her/his room door was open. Resident #1 said she/he was embarrassed by the situation and she/he asked the investigator to draw the privacy curtain closed to allow her/his privacy while on the commode.,2,,Not Substantiated,Substantiated, +ES149527,385185,NF,12/9/2014,"Evidence and interviews indicated facility failure to ensure adequate locked storage for Resident #1's gold wedding ring. On or about 11/22/14 witness #1 (facility staff) put Resident #1's ring in a locking drawer in the reception area. Witness #1 said she/he did not have access to the facility safe to secure Resident #1's ring. On or about 12/9/2014 facility staff determined Resident #1_x001A_s gold wedding band was missing or stolen from the locked drawer or locking safe. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining a loss of personal property is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,400,Substantiated,Substantiated,Financial abuse +ES149634B,385185,NF,11/23/2014,"Evidence and interviews indicated an unknown individual stole $51.00 from Resident #1's room. Resident #1 had was offered locking storage when admitted to the facility and declined. After the theft, facility staff submitted for reimbursement of Resident #1's stolen money and again offered locking storage for valuables and money.",2,,Not Substantiated,Substantiated,Financial abuse +ES150300,385185,NF,2/17/2015,Evidence and interviews indicated facility failure to provide Resident #1 adequate care related to circumstances on or about 2/8/2015 when Resident #1 was found to have urine in her/his bedding and she/he was assisted to the lunchroom wearing her/his pajama top and pants.,2,,Not Substantiated,Substantiated, +ES150601,385185,NF,3/17/2015,Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 and Resident #2 on or about 3/17/2015 when Resident #2 hit Resident #1 on the back as they were passing each other in the hall. Resident #2 was not observed to have injury because of this incident.,2,,Not Substantiated,Substantiated, +OR0000937400,385185,NF,12/10/2014,Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to pressure ulcers. The facility failure to provide Resident #1 adequate services to prevent the development of pressure ulcers placed Resident #1 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000945900,385185,NF,1/26/2015,"Evidence and interviews indicated facility failure to thoroughly investigate Resident #2's fall with injury placing Resident #2 at risk for neglect of care. Evidence and interviews indicated facility failure to provide Resident #2 adequate fall interventions. Facility failure to provide Resident #2 a safe environment with adequate fall interventions resulting in Resident #2 sustaining a fall and requiring stitches for her/his injury are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended, relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000945902,385185,NF,1/26/2015,"Evidence and interviews indicated facility failure to provide Resident #1, Resident #3 and Resident #4 adequate care and services related to pressure ulcers. The facility failure to provide residents adequate care and services related to the prevention of skin break down placed Resident #1, Resident #3 and Resident #4 at risk for unmet needs. Relevant portions of the complaint report investigation pertaining to the failure to provide Resident #3 adequate care and services to prevent skin break down are attached.",2,,Not Substantiated,Substantiated, +OR0000946001,385185,NF,1/26/2015,"Evidence and interviews indicated facility failure to ensure that Resident #4 who entered the facility without pressure sores did not develop pressure sores. The facility failure to provide Resident #4 adequate care and treatment services to prevent the development of pressure sores resulting in Resident #4 developing a right heel pressure ulcer are violations of resident rights, are considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +ES151026A,385185,NF,3/23/2015,Evidence and interviews indicated the facility failed to adequately administer Resident #1's psychoactive medication as ordered from 1/22/2015 to 3/2/2015. The facility failure to adequately administer Resident #1's psychoactive medication as ordered placed Resident #1 at risk for unmet medication administration needs.,2,300,Not Substantiated,Substantiated, +ES151026B,385185,NF,3/23/2015,Evidence and interviews indicated facility failure to ensure Resident #1 was administered her/his evening medications on 3/8/2015. The facility failure to adequately administer Resident #1's medications as ordered placed Resident #1 at risk for unmet medication administration needs.,,,Not Substantiated,Substantiated, +OR0000961900,385185,NF,4/10/2015,"Evidence and interviews indicated facility failure to adequately monitor Resident #2's weight per their policy. The facility failure to adequately monitor Resident #2's weight per their policy, resulting in Resident#2's continued unplanned weight loss, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,400,Substantiated,Substantiated,Neglect +OR0000961901,385185,NF,4/10/2015,"Evidence and interviews indicated facility failure to adequately monitor Resident #2_x001A_s oral intake. The facility failure to adequately monitor Resident #2_x001A_s oral intake, resulting in Resident #2_x001A_s continued unplanned weight loss, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +ES148978,385185,NF,10/20/2014,"Based on evidence and interviews it was determined the facility failed to provide Resident #1 timely PRN (as needed) narcotic pain medication. The facility failure to timely administer Resident #1_x001A_s narcotic pain medication, resulting in Resident #1 sustaining discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,300,Substantiated,Substantiated,Neglect +ES149648,385185,NF,12/12/2014,"Evidence and interviews indicated facility failure to assure Resident #1 received care and services from staff including RP2 (CNA) who failed to treat Resident #1 with consideration, respect, and dignity.",2,,Not Substantiated,Substantiated, +ES133680,385185,NF,5/1/2013,Evidence and interviews indicated facility failure to adequately document Resident #1's treatment orders for dental care and weight records.,2,,Not Substantiated,Substantiated, +ES152678,385185,NF,8/29/2015,"Based on evidence and interviews it was determined facility staff failed to adequately administer Resident #1_x001A_s narcotic pain medication. Witness #3 (licensed nurse) indicated Resident #1_x001A_s pain medication was decreased by one-half dosage from 8/28/2015 to 9/1/2015. The facility failure to adequately administer Resident #1_x001A_s narcotic pain medication, resulting in Resident #1 sustaining continued pain and discomfort, is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,500,Substantiated,Substantiated,Neglect +ES152416,385185,NF,8/8/2015,"Evidence and interviews indicated facility failure to adequately assess and monitor Resident #1's injury of unknown origin to rule out abuse. The facility failure to adequately assess and monitor Resident #1's injury of unknown origin, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +ES165091,385185,NF,3/16/2016,"Evidence and interviews indicated RP2 (CMA) failed to adequately administer Resident #1, Resident #2, and Resident #3, pain medications resulting in residents sustaining continued pain and unreasonable discomfort, this failure is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,1500,Substantiated,Substantiated,Neglect +ES164769,385185,NF,2/24/2016,"Evidence and interviews indicated facility failure to protect Resident #1 from theft by RP2 (CNA). RP2 took Resident #1's debit card and cash (amounting to at least $41.76 in fraudulent debit charges and $15.00 in cash) on or about 2/24/2016. These failures are considered a violation of resident rights, considered financial exploitation and constitute abuse.",2,,Not Substantiated,Substantiated,Financial abuse +OR0000830300,385187,NF,5/16/2013,"Evidence and interviews indicated the facility failed to prevent injury while Resident #1 was transported in a wheelchair. As a result, Resident #1 sustained ankle and knee injuries. These failures are considered neglect of care and constitute abuse. Federal penalty recommended, relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000857800,385187,NF,10/14/2013,Evidence and interviews indicated the facility failed to ensure staff followed care planned interventions for transfer assistance for Resident #1 who required two-person assistance with transfers resulting in Resident #1 sustaining a non-injury fall. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +BC146007,385187,NF,1/15/2014,"Evidence and interviews indicated the facility failed to adequately administer Resident #1_x001A_s narcotic pain medication. The facility failure to provide Resident #1 appropriate pain control resulting in Resident #1 sustaining continued pain is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000878400,385187,NF,2/18/2014,"Evidence and interviews indicated facility staff #1 (CNA) failed to ensure professional standards of practice were followed for following care planned interventions for Resident #203 who sustained a fractured femur. Evidence and interviews indicated facility failure to ensure care-planned interventions for transfers for Resident #203 were followed; Resident #203 sustained a fractured femur. Facility failure to ensure Resident #203 was transferred with care planned interventions in place resulting in Resident #203 sustaining a fractured femur are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0001009200,385187,NF,9/30/2015,"Evidence and interviews indicated facility failure to follow physician orders to schedule a timely medical appointment for Resident #1 who needed an appointment with a Podiatrist. Between 9/16/2015 and 9/21/2015, there was no documented evidence of a follow up to a 9/16/2015 appointment request for Resident #1. A Podiatrist saw resident #1 on 9/22/2015. Facility failure to schedule a schedule a timely physician appointment for Resident #1 placed Resident #1 at risk for unmet needs.",2,,Not Substantiated,Substantiated,Neglect +OR0000687700,385188,NF,5/10/2011,"The facility failed to ensure staff #3 followed care planned interventions to prevent Resident #1_x001A_s May 7, 2011 fall. Resident #1 had complaints of slight shoulder pain after the fall however no obvious signs of injury or profound complaints of pain. Relevant portions of the survey complaint report are attached.",2,,Substantiated,Substantiated,Neglect +OR0000748600,385188,NF,3/6/2012,Evidence and interviews indicated the facility failed to ensure Resident #1's pressure alarm was operating. Resident #1 sustained a fall on 03/04/2012 and sustained a skin tear to the left elbow and a 5 x 3 cm bruise/bump to the right forehead.,2,0,Substantiated,Substantiated,Neglect +DA129685A,385188,NF,4/1/2012,Evidence and interviews indicated facility failure to protect Resident #1 from the theft of $8.00 and her/his purse.,2,0,Substantiated,Substantiated,Financial abuse +DA129685B,385188,NF,4/1/2012,Evidence and interviews indicated facility failure to ensure Resident #1 received ice pack treatments as ordered by a physician. Evidence and interviews indicated facility failure to follow standard practice of taking Resident #1's vitals when Resident #1 had complaints of chest pain.,2,0,Substantiated,Substantiated,Neglect +OR0000804400,385188,NF,1/17/2013,Evidence and interviews indicated facility failure to ensure an accurate nursing assessment of Resident #1's weight loss. Evidence and interviews indicated facility failure to attempt the physician's recommendation of an appetite stimulant and failure to consistently document alternatives and supplements offered when Resident #1 consumed less than 50 percent of her/his meals. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000917400,385188,NF,8/26/2014,Evidence and interviews indicated facility failure to follow physician orders regarding a follow up visit with a pulmonologist. Facility failure to follow physician orders placed Resident #2 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,450,Not Substantiated,Substantiated, +OR0000917401,385188,NF,8/26/2014,Evidence and interviews indicated facility failure to provide Resident #2 adequate care and services related to a change of medical condition. Facility failure to provide Resident #2 adequate care and services related to a change in her/his medical condition placed Resident #2 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000917402,385188,NF,8/26/2014,Evidence and interviews indicated facility failure to provide Resident #2 adequate care and services related to resident assessment. Facility failure to provide Resident #2 adequate care and services related to an assessment placed Resident #2 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000913500,385188,NF,8/7/2014,"Evidence and interviews indicated facility failure to conduct, document and sign accurate assessments of Resident #1's pressure ulcers placing Resident #1 at risk for unmet care and service needs. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +DA159956,385188,NF,1/17/2015,"Evidence and interviews indicated facility failure to adequately assess, intervene and provide oversight for Resident #1's chronic skin condition. Physician orders for Resident #1 indicated Resident #1 required weekly head to toe skin assessments beginning 12/8/2014, however there was no documentation Resident #1 received a skin assessment on 12/28/2014 or during the first week of January 2015. January 17, 2015 hospital emergency department notes indicated Resident #1 had two separate areas of excoriated skin on her/his left chest and four areas of excoriated skin on her/his right chest with several other red excoriated skin areas noted elsewhere on Resident #1's body. The facility failure to adequately assess and intervene with Resident #1_x001A_s worsening skin condition resulting in Resident #1 sustaining several areas of skin breakdown is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +DA150886,385188,NF,3/29/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from inappropriate sexual contact by RP2 (CNA) on or about 3/29/2015. Resident #1 said she/he woke up while sleeping in bed on 3/29/2015 and RP2 had her/his hand down Resident #1's underwear, stroking Resident #1's private area. Resident #1 said she/he felt, ""...embarrassed...violated...and scared_x001A_"" after RP2 left her/his room, however she/he did not feel safe talking with anyone at the facility about what RP2 did to her/him. Resident #1 moved out of the facility and reported the 3/29/2015 incident with RP2 to a caregiver at a new facility on 4/6/2015. The facility conducted an internal investigation regarding Resident #1's allegation of RP2's inappropriate sexual contact, however failed to report to The Department or local law enforcement regarding the alleged sexual abuse. The facility failure to protect Resident #1 from inappropriate sexual contact by RP2 resulting in Resident #1 sustaining sexual abuse, embarrassment and fear is a violation of resident rights, considered neglect of care, and constitutes abuse.",4,2800,Substantiated,Substantiated,Sexual abuse +DA150078B,385188,NF,12/17/2014,"Evidence and interviews indicated facility failure to report potential or suspected sexual abuse of Resident #1 by RP2 (CNA) to law enforcement, Adult Protective Services or The Department. + + + +The facility failure to adequately report potential or suspected abuse of Resident #1 exposed Resident #1 and other facility residents to immediate jeopardy of sexual abuse, failing to ensure the care and safety needs of facility residents were met.",4,250,Not Substantiated,Substantiated, +DA152150,385188,NF,7/17/2015,"Evidence and interviews indicated facility failure to provide Resident #1 a safe environment related to circumstances with RP2 (facility staff) on or about 7/17/2015. Resident #1's care plan dated 6/12/2015 indicated Resident #1 had conflicts with staff and staff were to set clear boundaries while maintaining professionalism, acting with a calm non-threatening manner. Resident #1 shoved RP2 on 7/17/2015 and RP2 ""slapped"" Resident #1 on her/his left shoulder. RP2 said she/he did not receive any training regarding abuse and since the event, she/he was instructed not to touch any residents. Resident #1 indicated she/he and RP2 were playing and no harm was noted to Resident #1 because of this incident.",2,,Not Substantiated,Substantiated, +SV116336,385189,NF,2/11/2011,Evidence is insufficient to prove theft of medication. Medication may have been improperly disposed of and or the medication may have been lost. RV had requested to take the medication with them and staff should have contacted RV's physician for an order to send the medication with the resident. The facility offered to credit RV's account for the two medications. Staff will receive re-education pertaining to narcotic dispensing and documentation per W2.,2,0,Not Substantiated,Substantiated, +SV116606,385189,NF,3/7/2011,"RP2 mumbled under his/her breath within ear shot of RV3 an inappropriate comment. W1 and W2 perceived RP2's care as rough when RP2 alleged he/she was being efficient. None of the RVs reported poor care and/or refused to speak to the investigator. Evidence is insufficient for abuse, but RP2 failed to treat RV3 with all due respect.",2,0,Not Substantiated,Substantiated, +OR0000677300,385189,NF,3/21/2011,"Resident 1 was admitted on 2/15/11 with multiple diagnoses including CHF and COPD. The facility failed to follow professional standard of care by not informing his/her physician that the resident's legs were weeping. The facility failed to assess and obtain treatment orders for non-pressure ulcers and failed to obtain a physician order for a salt substitute as RD advised. Resident 1 refused hospitalization on 3/4/11 physician visit. Resident 1's medication was adjusted. On 2/22/11 staff failed to follow physician orders regarding weight gain and edema. Resident 1 gained 5 pounds in one day without physician notification. Documentation regarding Resident 1's changing condition, fluids, etc. was inadequate. Relevant portions of the survey are attached. A directed in-service was proposed.",2,0,Not Substantiated,Substantiated, +OR0000680202,385189,NF,4/4/2011,"Resident 3's family member was not informed of Resident 3's right foot/toe sores. On 3/25/11 staff found unopened blisters to the right foot, physician was notified and treatment was given, but there is no evidence the family was notified. There was no investigation of the right foot blisters. Relevant portions of the survey are attached. Enforcement action in the form of a directed in-services was proposed.",2,0,Not Substantiated,Substantiated, +SV104757,385189,NF,6/29/2010,"RV did not receive ordered over the counter medication from 6/23/2011 through 6/29, 2011. Evidence is inconclusive whether or not RV's hospital transfer was related to the missed medication. Staff received in-service after this incident.",2,0,Not Substantiated,Substantiated, +OR0000709700,385189,NF,8/22/2011,"Resident 1 was admitted 7/27/11 with multiple diagnoses and assessed potential for nutritional/hydration impairment. Resident 1 was weighed daily for 72 hours and then weekly; weight increased from 187.1 to 193.2 lbs. from 7/27/11 to 7/30/11. Resident 1 was assessed with fluid requirement between 2,125 and 2,550, but the most recorded was below 1,800 and urine output was noted as 600 cc on 7/27/11 without further specific out put recorded. The July and August treatment sheets nor the resident care plan contained information regarding potential leg edema or any treatments to the lower leg. The first mention of pitting lower leg edema was on 7/28/11 at 3:30 P.M. and a night shift note indicated increased edema. Nursing notes from 7/29/11 through 7/30/11 did not mention lower leg edema. ON 8/2/11 day shift lower extremity edema and a large skin tear to the left shin was found. Resident 1's physician was faxed regarding the skin tear, but no mention of the severe edema was noted in the fax. W1 indicated no one told him/her that Resident 1 was not complying with physician orders to elevate his/her legs.. Staff failed to promptly notify Resident 1's physician or care plan for Resident 1's increased weight gain, increased leg edema, left leg skin tear, less than adequate fluid intake/urine out put and decreased sensorium.",3,450,Substantiated,Substantiated,Neglect +SV117281,385189,NF,4/20/2011,"RV reported RP2 ""yelled and was mean to RV"" and called RV a ""mental case."" RV reported to the investigator being mad and just staying in his/her room when RP2 was working. RP2 was not directly interviewed, but an internal investigation dated 6/22/11 noted RP2 stated that RV shared personal information. The internal investigation showed RP2 suggested RV see a psychiatrist. Evidence does not support verbal abuse, but RP2 made an unsolicited response to RV's sharing of personal information. RP2 was counseled regarding personal boundaries with residents. RP2 was offered another floor to work.",2,0,Not Substantiated,Substantiated, +OR0000705600,385189,NF,8/8/2011,"Resident 1 was admitted 7/21/11 with multiple diagnoses including a chronic left leg ulcer, as well as, a Stage IV ulcer to the right buttocks. Resident 1 discharged to the hospital on 7/25/11 with the hospital describing a Stage II to the buttocks. Resident 1's care plan of 7/25/11 indicated ""skin integrity impaired"" to the right buttocks, but did not indicate appropriate care for the ulcers. The Nurse Aide form did not contain information or instructions regarding Resident 1's skin. Resident 1's physician ordered dressing changes to the left buttocks, but there were days in July and August the dressing was not changed. Resident 1 refused care at times and was unable to recall if a pressure relief pad was used in the wheel chair. Relevant portions of the survey are attached. Enforcement action was recommended.",2,0,Not Substantiated,Substantiated, +SV118241,385189,NF,10/4/2011,RV was admitted to the facility 10/4/11 at 6:15 P.M. with two prescriptions for narcotics. Staff called the VA hospital at approximately midnight as the prescription were not filled by the pharmacy due to inadequate Rx for quantity. Staff attempted to contact the VA and RV's physician. RV was given Tylenol and denied being in much pain. Staff failed to call the house physician to gain more timely orders.,2,0,Not Substantiated,Substantiated, +OR0000723101,385189,NF,10/27/2011,Resident 1 was admitted 2010 with assessed need for total personal care. On 11/20/11 surveyors observed Resident 1's toe nails were long. W1 reported visiting Resident 1 four times per month and the resident's nails were long. Staff reported CNAs were to trim Resident 1's toe nails. Staff 2 reported no area to document nail care. Relevant portions of the survey are attached. Enforcement action was recommended.,2,0,Not Substantiated,Substantiated, +OR0000724302,385189,NF,11/1/2011,Staff 2 (DNS) stated the facility did not have a written policy/procedure for cleaning/sanitizing bed pans. Staff 7 and 8 gave varied accounts as to the procedure for cleaning/sanitizing bed pans. Relevant portions of the survey are attached. Enforcement action was recommended.,2,0,Not Substantiated,Substantiated, +MV117694A,385189,NF,5/9/2011,"On 8/11 RV stated that a ring was missing. The inventory sheet showed a silver ring that RV did not receive at discharge, but RV did receive a yellow band and a bracelet. The facility offered to reimburse with a statement or receipt for the ring. The facility failed to ensure a safe environment resulting in missing RV property. An Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Financial abuse +MV134417,385189,NF,9/11/2013,"RV reported a loss of $85.00 between readmission August 2013 and September 2013. The facility offered lockable space and use of a safe, but RV declined. RV was in the rehabilitation portion of the facility and evidence is not conclusive if lockable space was offered in these rooms. The facility failed to provide a safe and secure environment resulting in loss of a resident's monies. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +MV148183,385189,NF,8/10/2014,"Evidence and interviews indicated facility failure to provide adequate transfer assistance for Resident #1. Resident #1 said there were two different times she/he was provided transfer assistance and a bar on the Hoyer lift hit her/him in the head. Witness #4 (licensed nurse) indicated Resident #1 was struck on the head by a crossbar on a Hoyer lift on 8/10/2014. The facility failure to ensure adequate transfer assistance for Resident #1 resulting in Resident #1 sustaining pain and bruising is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MV159823,385189,NF,1/7/2015,"Evidence and interviews indicated facility failure to administer medication as ordered for Resident #1's PRN (as needed) pain medication. The facility failure to ensure the timely administration of Resident #1's pain medication resulting in Resident #1 experiencing continued pain and suffering is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000939000,385189,NF,12/16/2014,"Evidence and interviews indicated facility failure to monitor and care plan for Resident #4_x001A_s diabetes and contact the physician regarding orders for diabetic monitoring. Facility failure to adequately monitor and care plan for Resident #4_x001A_s diabetes resulting in Resident #4 sustaining elevated blood sugars requiring emergency hospital treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,400,Substantiated,Substantiated,Neglect +OR0000946400,385189,NF,1/28/2015,"Evidence and interviews indicated facility failure to ensure pain medications were available on-site for Resident #10 who required medication to manage pain. Resident #10 had orders for pain medication every four hours PRN (as needed). A 1/24/2015 facility fax indicated there was no remaining balance of Resident #10's pain medication. Between 1/22/2015 and 1/26/2015 there was no documented evidence the facility contacted the physician or followed up the pharmacy about the need for additional pain medication. According to a 1/2015, medication administration record for Resident #10 she/he was administered two tablets of pain medication on 1/25/2015. On 1/26/2015, Resident #10 had complaints of pain; there was no remaining pain medication. Facility staff asked Resident #10 if she/he wanted to be transported to the hospital; Resident #10 said yes. Relevant portions of the complaint report investigation are attached.",2,600,Substantiated,Substantiated, +MV149492,385189,NF,12/3/2014,"Evidence and interviews indicated facility failure to ensure adequate administration of Resident #1_x001A_s scheduled pain medication on or about 12/4/2014. Facility failure to provide Resident #1 adequate pain medication administration resulting in Resident #1_x001A_s pain and suffering continuing is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,500,Substantiated,Substantiated,Neglect +MV151730,385189,NF,5/1/2015,"Evidence and interviews indicated RP2 (licensed nurse) financially exploited Resident #1 when accepting gifts and cash in excess of $68,100.00 for RP2's personal gain and profit while providing care for Resident #1 at the Facility. The facility failure to protect Resident #1 from RP2 financially exploiting Resident #1 is a violation of resident rights, considered financial exploitation, and constitutes abuse.",4,,Not Substantiated,Substantiated,Financial abuse +WB151811,385189,NF,7/5/2015,"Evidence and interviews indicated facility failure to provide Resident #1 a safe environment related to her/his repeated elopements. Resident #1 left the facility unattended once in April 2015, on 7/2/2015, 7/4/2015 and 7/6/2015. Resident #1 was issued a move-out notice after her/his elopement from the facility on 7/6/2015.",2,,Not Substantiated,Substantiated, +OR0000969000,385189,NF,5/13/2015,"Evidence and interviews indicated facility failure to ensure adequate documentation, assessment and care for Resident #3_x001A_s pressure ulcers. The facility failure to provide Resident #3 adequate care and treatment services for pressure ulcers, resulting in Resident #3_x001A_s pressure ulcers worsening, is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached. + + + +Note: Evidence and interviews failed to indicate facility failure to ensure adequate documentation, assessment and care for Resident #1_x001A_s pressure ulcers.",3,400,Substantiated,Substantiated,Neglect +MV164303C,385189,NF,1/4/2016,"Evidence and interviews indicated facility failure to adequately provide for Resident #1's dietary needs as ordered by a physician. Facility failure to ensure Resident #1 was provide meals and snacks as ordered on or about 1/4/2016, resulting in Resident #1 sustaining hunger is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +MV165203,385189,NF,3/7/2016,"Evidence and interviews indicated facility failure to protect Resident #1 from receiving rough treatment with care assistance provided by RP2 (CNA) on or about 3/17/2016. Facility failure to ensure adequately trained staffing and facility failure to protect Resident #1 from rough care assistance resulting in Resident #1 sustaining rough treatment while receiving care assistance, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Physical Abuse +OR0000650400,385190,NF,11/29/2010,"Resident 1 was admitted on 10-19-10 with multiple diagnoses including dehydration, hypernatremia, diabetes insipidus, renal insufficiency and mental health issues. Resident 1's 10-29-10 assent did not address or assess factors that put Resident 1 at risk for dehydration. Resident 1's meal monitoring indicated Resident 1 had not consumed 2 liters of fluid on any day; many days the fluid intake sections were blank. Resident 1' care plan did not address fluid enhancement. Resident 1's medical record did not indicate facility knowledge that Resident 1 had not met the physician's ordered fluid minimums. Resident 1 was transferred to the hospital on 11-27-10 with signs/symptoms of dehydration. The hospital documentation noted Resident 1 to have ""appears 4 liter water deific"". Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000651400,385190,NF,12/3/2010,Resident 2 was admitted 10-2010 with diagnoses including chronic back pain and atrial fibrillation. Resident 2's assessment and care plan identified a risk for falls and required extensive assistance with transfers. RP2's care plan dated 10-15-10 did not specify how the resident was to be transferred. Resident 2's physical therapy summary revealed a 75% assist with a two person transfer. Staff transferred Resident 2 alone and Resident 2 sustained a lower leg laceration requiring hospital treatment. Staff 3 reported the Status Sheets for Resident 2 were not available. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000656300,385190,NF,12/22/2010,"Resident 1 was admitted 11/20/10 with diagnoses including Type I diabetes. Resident 1 received CBGs, insulin, etc. while in the facility. Resident 1 was discharged to another facility on 12/17/10 with staff failure to include Resident 1's insulin and CBG regime. Resident 1's insulin record were not included with a copy of the TAR and MAR that was sent to the second facility. Staff failure to send information regarding Resident 1's diabetes and treatment resulted in Resident 1 sustaining a negative physical effects.",3,0,Substantiated,Substantiated,Neglect +OR0000706500,385190,NF,8/11/2011,"Resident 1 was admitted to the facility on 6/28/11 with multiple diagnoses including fusion of C2 through T2. Resident developed an infection while in the hospital with subsequent surgeries and use of a Halo brace. Wound staples were to be removed after 6/14/11. Resident 1's admission orders did not include care for the neck staples. Staff 3 documented the neck staples were visualized on the back at top of the neck, contacted the neurosurgeon's office and left a message regarding the staples; no evidence the facility contacted the surgeon's office again when there was not response. On 8/9/11 purulent drainage/odor was coming from the back dressing. Resident 1 was sent for evaluation and admitted to the hospital. Staff 3 reported telling Staff 4 of the staples, but Staff 4 does not recall this. Staff 3 failed to initiate a skin assessment sheet for staff to monitor the skin/staple area. The 24 hour report did not contain an alert to other staff . The facility failed to provided adequate care and services regarding wound care. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000717901,385190,NF,9/28/2011,"Resident 2 was admitted with diagnoses including fractures and atrial fibrillation at times. The physician ordered of 8/25/11 revealed multiple medication orders. On 9/6/111 antibiotics were ordered, but the resident refused all medications from 9/7/11 through 9/10/11. Staff were aware of the resident s change of condition at 10:00 A.M., called the physician's office and the MA asked for staff to wait for his her call back, but this did not occur. Staff failed to provide immediate interventions, call 911 and send Resident 2 to the ER. Relevant portions of the survey are attached. Enforcement action was taken.",2,0,Not Substantiated,Substantiated, +OR0000717902,385190,NF,9/28/2011,the facility had problems with homeless people entering the facility in years past. Signs were posted to lock the front doors between 5:30 P.M. and 5:30 A.M. The facility failed to maintain a safe environment by not locking the front entrance as per sign posted.,1,0,Not Substantiated,Substantiated, +OR0000737201,385190,NF,12/29/2011,"Resident 1 was admitted 12/8/11 with multiple diagnoses and physician orders were provided. The 12/8/11 physician orders lacked directives regarding tracheostomy care or cleaning. The 12/2011 TAR lacked documentation regarding tracheostomy care/cleaning, but the IDT notes indicated inconsistent documentation the care was completed. Staff gave conflicting information the tracheostomy care. Staff 2 was unable to provide evidence of a comprehensive assessment of the tracheostomy and stated the physician should have been contacted for clarification of care. The facility failed to appropriately care plan for the care of Resident 1's tracheostomy. The facility failure place Resident 1 at risk for harm and represents a Oregon Administrative Rule violation. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +BC121192,385190,NF,9/18/2012,"The facility failed to ensure a safe medication system resulting in RV1 receiving RV2's pain medication. RV1 reported he/she went to sleep, but didn't have any other adverse effect. W3 had attempted to give RV2' his/her poured medication, placed the medication in the cart and told W2 that a certain room required medication. W2 misunderstood the room number and gave RV1 the medication poured for RV2. W2 and W3 failed to follow the 5 Rights of medication administration. The facility has now instructed all staff who pour the medication will give the medication. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +BC121385,385190,NF,10/10/2012,Evidence supports RP2's failure to answer resident's call lights promptly. RP2 and W4 reported RP2 did give RV3 a bath. Evidence is inconclusive whether or not RP2 was rough in providing assistance to RV1. RV1 has no sign of injury. The facility failure represents an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +OR0000804900,385190,NF,1/18/2013,"Resident 1 was admitted December 20, 2012 with multiple diagnoses. Resident physician orders of 12/29/12 included anti-anxiety, anti-psychotics, anti-depressants and pain medication. The facility failed to ensure the risk versus benefits of medication used and failed to document the effectiveness of the PRN pain medication. The facility failed to use non-pharmacological interventions prior to using PRN antianxiety medication. The resident was transferred to the hospital for further evaluation. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000880800,385190,NF,3/4/2014,"Resident 1 was admitted 2/24/2014 with multiple diagnoses. Resident's hospital orders for discharge included CBGs and insulin based on the CBG levels. Record review found resident CBGs and Insulin was not always checked and or given as ordered from 2/24/2014 through 2/26/2014. staff reported on 2/26/2014 a computer system failed and medication orders did not transfer from the MAR to the DAR. The resident did not receive CBG checks and Insulin before breakfast and dinner on 2/26/24, the resident developed extremely high blood sugar, acute kidney injury and hospitalization. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +BC147519,385190,NF,6/19/2014,"Multiple witnesses reported RV can be resistive to care. W3 stated RP2 admitted to ""pushing"" RV's hands to RV's chest to keep RV from striking out. W3 also stated RP2 admitted to holding RV's hands to take RV's blood pressure. W4 observed both events, but failed to immediately report the 6/19/2014 first event until 6/21/2014. W4 did immediately report the second event of 6/21/2014. RP2 had signed an abuse form on 4/14/2014 which included controlling behavior. RV did not sustain physical injury, RP2 reported using a technique he/she had ""learned"" in a previous facility and did not think what she/he had done was wrong., RP2 used force to control RV's behaviors which constitutes abuse., RP2 violated RV's resident's rights to refuse care. Staff failed to immediately report suspected abuse. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Physical Abuse +BC148290,385190,NF,8/26/2014,"RV receives medication every two hours. On 8/1/2014 at 2:10 P.M. RP2 went to give RV the medication; RV was in the bathroom; and RP2 forgot to go back and give RV the medication. RP2 had charted the medication as given prior to giving medications to RV and others. RV missed a dose of medication. Evidence was inconclusive for the effect of the missed the medication except RV reported "" RV reported he/she freezes. Staff received further in-services. Oregon Administrative Rule violations.",2,,Not Substantiated,Substantiated, +OR0000900700,385190,NF,6/2/2014,"Resident 1 was admitted 4/27/2014 with multiple diagnoses and physician ordered medication including Coumadin. Resident received Coumadin from 5/13/2014 through 5/22/2014 after a 5/12/2014 physician ordered to hold the medication and a lab work order for 5/15/2014 was received. No PT/INR lab slip could be found for 5/15/2014; no lab work was completed. Staff 5 reported not being sure if a lab slip for the PT/INR was created. Staff 2, 3 and 4 all deny any physician orders were placed in Staff 3's box for review. Staff 5 reported placing the orders in the box for review and placing the order in the electronic MAR; no evidence was found to support this statement. Additionally Resident 1 received Coumadin on 5/11/2014 although a physician order was in place to hold the medication at this time, too. Resident 1 sustained a change of condition on 5/23/2014, transferred to the hospital and was diagnosed with a subdural hematoma, as well as, supra therapeutic INR. The facility failed to provide necessary care and services. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +BC148910,385190,NF,10/6/2014,"Based on evidence and interviews it was determined the facility failed to protect Resident #1 and Resident #2 from RP2 (C.N.A.) raised voice when providing care. W5 was in RV1's room and reported RP2 told RV 1 ""this is what we are using or you are not getting up for lunch or to play bingo"". W5 also reported earlier in the morning going to RV2's room and hearing RP2 ""yell"" at RV2. W5 reported RP2 ""roughly"" put on RV2's socks. Further interview during an informal conference with RP2 found RP2 was attempting to encourage residents to get up for lunch and bingo; RP2 reported residents could stay in bed to eat, but knew RV1 liked to play bingo. RP2 stated in hindsight he/she could have offered to come back and take RV1 to bingo, but thought there would not be enough time. RP2 reported assisting staff who was not familiar with the residents and this was putting them behind in care. RP2 admitted RV2 was kicking at RP2 and RP2 was having a rough time putting on RV2's socks. Reviewer notes W5 may have misinterpreted the application of sock as being rough. RP2 reported RV2 did not complain of pain, but was showing some resistance. RP2 failed to follow RV2's care plan and seek licensed help and or use of medication. RP2 conceded he/she should have stopped and come back to RV2, but was attempting to get RV2 ready for lunch. RP2 received disciplinary action in the past regarding his/her tone of voice. RP2 has completed further in-service regarding stress management and Reasoning With Unreasonable People: Focus on Disorders for Emotional Regulation; and able to express understanding of what he/she did wrong in the prior incidents. The facility failed to properly supervise RP2's interaction with residents following a disciplinary action; and which resulted in RP2's failure to provide less than stellar care while ensuring resident choice was honored. Oregon Administrative Rule violations occurred.",2,400,Not Substantiated,Substantiated, +BC148872A,385190,NF,10/7/2014,"The complainant reported RV was left in a wet brief for two hours the evening of 10/7/2014, as well as , other times. RV reported waiting half an hour for assistance with incontinence and three other occasions waiting for call light response. RV also stated he/she may be mixing up his/her days. RP2 looked at the call log and believes he/she forgot to turn off the call light, denied telling RV he/she would return after finishing dinner. RP2 recalled how busy the night was with feeding resident, passing trays and the other care giver was busy. The facility will begin to monitor call light response. The facility failed to promptly respond to RV's call light. Lack of timely response to RV call light and being left in soiled garments constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +BC149239,385190,NF,11/4/2014,"RP4 reported directing two aides to hold RV2's arm while RP4 administered a TB test. RV2 became upset and complained following the procedure. RV2 had told RP4 RV2 did not want a ""shot"", but RP4 did proceed after telling RV the test had to be done. RP4 failed to follow facility procedure and or inquire if another avenue could be used; use of an x-ray instead of the TB test using a needle. Holding RV2's arm and restraining RV to perform the TB test constitutes physical abuse. Additionally RV2's right to choice of treatment was violated. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Physical Abuse +OR0000947500,385190,NF,2/5/2015,Staff 4 failed to follow physician orders regarding Resident 1's weight monitor and reporting to the physician. Resident 1 with a diagnosis of CHF gained 5.1 pounds of weight in 24 hours which should have been reported to the resident's physician per the resident's physician order and as a standard of care. Staff 5 contacted the physician the next morning (1/26/15) regarding the 5.1 gain noted 1/25/15 and the additional weight gain of 6.1 on 1/26/15 along with signs of resident distress. The resident was sent to the hospital at physician order on 1/26/15. Relevant portions of the survey are attached. Enforcement action was taken. Oregon Administrative Rule violations occurred.,2,,Inconclusive,Substantiated, +BC151568,385190,NF,6/11/2015,"RP2 in an attempt to make RV happy applied ice to RV's leg without a license nurse consult. RP2's actions were out of scope of practice. While RV sustained a blister to the area, RV had used an ice pack before, was capable of removing the pack and chose not to. Oregon Administrative Rule violations' occurred.",2,,Not Substantiated,Substantiated, +HB133069,385195,NF,4/23/2013,"Evidence and interviews indicated facility failure to ensure a safe medication administration system. This failure placed Resident #1, Resident #2 and all facility residents at serious risk of losing prescribed narcotic medication administration.",3,400,Not Substantiated,Substantiated, +OR0000838900,385195,NF,7/3/2013,"Evidence and interviews indicated facility failure to meet professional standards of care regarding Resident #1's safety from heat exposure. Resident #1 was left outside in hot weather for 2.5 hours, became unresponsive and required emergency treatment for heat stroke at the hospital. These failures are considered neglect of care and constitute abuse. Federal penalty recommended, relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000900500,385195,NF,6/2/2014,"Evidence and interviews indicated facility failure to ensure Resident #1's wheelchair brakes adequate transfer assistance related to a 05/27/2014 incident where Resident #1 was assisted from her/his wheelchair to the toilet and fell. The facility failure to ensure adequate transfer assistance resulting in Resident #1 falling, hitting her/his head on the floor and sustaining a head injury that required emergency room treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +HB147776,385195,NF,7/16/2014,"Evidence and interviews indicated RP2 (CNA) took Resident #1's checkbook, took out check #1021, dated the check 5/29/2014 and made the check payable to RP2 in the amount of $960 for caregiving services provided to Resident #1. On or about 07/2/2014, RP2 cashed Resident #1's check number 1021 for $960 and used the money for his personal needs. The facility failure to protect Resident #1 from RP2 financially exploiting Resident #1 constitutes abuse.",3,200,Not Substantiated,Substantiated,Financial abuse +HB153230,385195,NF,10/21/2015,"Evidence and interviews indicated facility failure to administer Resident #1's flu vaccination as ordered on or about October 16, 2015 when the facility administered Resident #1 two vaccinations instead of one in error. According to evidence and interviews, Resident #1 did not sustain adverse symptoms or side effects from the medication error.",2,,Not Substantiated,Substantiated, +OR0001002900,385195,NF,9/14/2015,"Evidence and interviews indicated facility failure to ensure accurate care plan approaches for Resident #2, placing Resident #2 at risk for injury.",2,,Not Substantiated,Substantiated, +OR0001002901,385195,NF,9/14/2015,"Evidence and interviews indicated the facility failed to ensure staff followed care plan approaches for the use of a gait belt to Resident #2. Facility failure to ensure staff used a gait belt while assisting Resident #2 with transferring from the toilet to a wheelchair on 9/10/2015, resulting in Resident #2 sustaining a fall with injury is considered neglect of care and constitutes abuse; relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +HB153651,385195,NF,11/15/2015,"Evidence and interviews indicated RP2 (housekeeper) failed to assure Resident #1's right to receive services in a dignified, respectful manner when directing Resident #1 to ""shut up"" from the hallway outside of Resident #1's room. RP2 admitted to telling Resident #1 to shut up, however thought no one could hear what she/he said. RP2 was suspended pending an investigation and terminated after the incident.",2,,Not Substantiated,Substantiated, +MS118256,385197,NF,10/2/2011,Evidence and interviews indicated RP2 (licensed nurse) administered incorrect medication to Resident #1 on 10/2/2011. Resident #1 was placed on alert charting for 72 hours with no adverse side effects noted from the medication error.,2,0,Not Substantiated,Substantiated, +MS118493,385197,NF,11/17/2011,Evidence and interviews indicated facility failed to ensure Resident #1 received adequate toileting assistance resulting in Resident #1 sustaining two incidents of incontinence while in bed.,2,250,Substantiated,Substantiated,Neglect +MS129811,385197,NF,4/18/2012,"On April 18, 2012 RP2 (CNA) assisted Resident #1 onto a bedpan. RP2 left Resident #1 sitting on the bedpan while RP2 went to lunch. Resident #1 sustained a _x001A_2 cm welt where bedpan was"" on RV_x001A_s buttocks as a result of sitting on the bedpan for an extended period of time. RP2 had prior facility write-ups consistent with the investigated incident.",2,250,Substantiated,Substantiated,Neglect +MF121653A,385197,NF,11/17/2012,On 11/17/2012 RP2 (licensed nurse) erroneously administered Resident #2_x001A_s medications to Resident #1. Resident #1 experienced sedation from receiving incorrect medication and required monitoring for 72 hours. The facility failure to provide an adequate medication system is considered neglect of care and constitutes abuse.,2,250,Substantiated,Substantiated,Neglect +MF121653B,385197,NF,11/17/2012,"Resident #1 had a history of refusing medications and becoming verbally aggressive with other residents. On 10/16/2012 Resident #2 was verbally aggressive toward Resident #1 causing Resident #1 to be fearful of Resident #2. Resident #1 and Resident #2 shared a room at the facility from 10/16/2012 through 11/29/2012. Evidence and interviews indicated facility failure to ensure adequate interventions regarding Resident #2's behavior toward Resident #1, this failure constitutes neglect of care and is considered abuse.",2,0,Substantiated,Substantiated,Neglect +MS132247,385197,NF,1/17/2013,"Based on interviews and evidence it was determined the facility failed to ensure Resident #1, Resident #2 and Resident #3 were provided medication and treatments as ordered This failure is considered a violation of Oregon Administration Rules.",2,750,Not Substantiated,Substantiated, +MS133447,385197,NF,6/7/2013,Evidence and interviews indicated facility failure to provide adequate interventions for Resident #2's known behaviors resulting in Resident #1 and Resident #2 sustaining an altercation with Resident #1 becoming very upset.,2,,Not Substantiated,Substantiated, +MS133646B,385197,NF,5/3/2013,Evidence and interviews indicated facility administered Resident #1 psychotropic medications at least twice after the physician discontinued Resident #1's psychotropic medication on 05/13/2013.,2,,Not Substantiated,Substantiated, +MS134193,385197,NF,8/19/2013,Evidence and interviews indicated facility failure to ensure a safe environment and adequate interventions for residents related to a dining room incident where Resident #1 became agitated and slapped Resident #2's hand.,2,,Not Substantiated,Substantiated, +OR0000860200,385197,NF,10/28/2013,"Evidence and interviews indicated facility failure to administer anti-coagulation medication for Resident #2, Resident #6, Resident #7 and Resident #8. The Facility_x001A_s failure to ensure residents anti-coagulation medication was administered as ordered placed Resident #2, Resident #6, Resident #7 and Resident #8 at risk for complications to their individual medical conditions. Relevant portions of the complaint report investigation are attached.",2,1000,Not Substantiated,Substantiated, +OR0000860201,385197,NF,10/28/2013,Evidence and interviews indicated facility failure to document the respiratory equipment used for Resident #2 who had a physician order for a Biphasic Positive Airway Pressure (BIPAP) machine. The October 2013 Treatment Authorization Request (TAR) indicated Resident #2_x001A_s BIPAP was not documented from 10/15/2013 through 10/24/2013. The Facility_x001A_s failure to document Resident #2_x001A_s BIPAP treatment was administered as ordered placed Resident #2 at risk for inadequate respiratory status. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +MS146228,385197,NF,2/28/2014,Evidence and interviews indicated facility failed to provide Resident #1 a safe environment related to an incident on 02/28/2014 where RP2 (facility staff) closed the door to Resident #1's room and turned off the lights.,2,,Not Substantiated,Substantiated, +MS146821,385197,NF,4/12/2014,"Evidence and interviews indicated facility failure to ensure adequate peri care when Resident #1 and Resident #2 were not provided night briefs on 04/12/2014 as indicated per facility protocol. Morning staff found Resident #1 and Resident #2 in urine-saturated briefs and bedding; Resident #2 had, _x001A_dried stool on buttocks and thighs._x001A_ The Facility failure to ensure Resident #1 and Resident #2 received adequate peri care resulting in them lying in urine soaked briefs and bedding overnight are violations of resident rights, are considered neglect of care and constitutes abuse.",2,400,Substantiated,Substantiated,Neglect +MS146819A,385197,NF,3/31/2014,"Evidence and interviews indicated facility failure to assure Resident #1's received care assistance and was treated with consideration, respect and dignity. Evidence and interviews indicated RP2 (CNA) provided residents care assistance with a ""harsh"" and ""aggressive"" attitude.",2,,Not Substantiated,Substantiated, +MS146819B,385197,NF,3/31/2014,"Evidence and interviews indicated facility assure appropriate toileting and incontinence assistance for Resident #1 and Resident #3 on at least two separate occasions. The facility failure to assure Resident #1 and Resident #2 received adequate toileting assistance are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MS147447,385197,NF,6/18/2014,"Evidence and interviews indicated facility failure to provide Resident #1 appropriate pain control. Documentation indicated Resident #1 was admitted to the facility from the hospital without a written physician order for pain medication on 6/17/2014 at 2:45 pm. Facility staff administered Resident #1's first dose of scheduled pain medication approximately eight hours late. + +The Facility failure to ensure Resident #1 was adequately administered pain medication resulting in Resident #1's pain and suffering continuing are violations of resident rights, are considered neglect of care and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000896300,385197,NF,5/12/2014,Evidence and interviews indicated facility failure to follow procedures to investigate Resident #1's unwitnessed fall or skin tear and bruises of unknown origin.,2,,Not Substantiated,Substantiated, +OR0000896302,385197,NF,5/12/2014,"Evidence and interviews indicated facility failure to complete the minimum data set (MDS) pain assessment dated 11/22/12 for Resident #1. In addition, evidence and interviews indicated Resident #1's knee pain was managed with Tylenol until Resident #1's knee was noted as swollen. The facility notified the physician who prescribed Resident #1 a narcotic pain reliever.",2,,Not Substantiated,Substantiated, +MS148373,385197,NF,9/3/2014,Evidence and interviews indicated facility failure to ensure that RP2 (CNA) and RP3 (licensed nurse) provide adequate medical care and treatment related to Resident #1's compression socks. On or about 8/30/2014 facility staff failed to remove Resident #1's compression socks as noted by witness #2 (licensed nurse) on or about 08/31/2014 at 7:00 am.,2,,Not Substantiated,Substantiated, +OR0000911000,385197,NF,7/23/2014,Evidence and interviews indicated facility failure to accurately transcribe physician_x001A_s orders for medication for Resident #1 and Resident #2. The facility failure to accurately transcribe physician_x001A_s orders for Resident #1 and Resident #2 resulting in resident_x001A_s not receiving medications as ordered placed residents at risk. Relevant portions of the complaint report investigation are attached.,3,500,Not Substantiated,Substantiated, +OR0000928100,385197,NF,10/20/2014,Evidence and interviews indicated facility failure to investigate an injury of unknown cause and to conclusively rule out abuse or neglect for Resident #59 who had an unwitnessed fall with injury. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000939200,385197,NF,12/16/2014,"Evidence and interviews indicated facility failure to investigate an injury of unknown cause and to conclusively rule out abuse or neglect related to circumstances with Resident #1 who sustained an unwitnessed fall or injury, placing Resident #1 at an increased risk for injury. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +MS150304,385197,NF,12/23/2014,Evidence and interviews indicated facility failure to ensure Resident #1 received adequate peri-care on or about 12/23/2014. RP2 (CNA) assisted Resident #1 with changing her/his brief after an episode of bowel incontinence. RP2 ran out of adequate supplies to assist Resident #1 with cleaning-up and asked witness #1 (facility staff) to assist Resident #1 as it was shift change. Witness #1 assisted Resident #1 with cleaning up and changing after witness #1 after she/he first checked other facility residents.,0,,Not Substantiated,Substantiated, +MS159861B,385197,NF,1/8/2015,Evidence and interviews indicated facility failure to notify the Division regarding Resident #1's unwitnessed fall with injury on or about 10/31/2014.,2,,Not Substantiated,Substantiated, +MS151516,385197,NF,6/10/2015,"Evidence and interviews indicated RP2 (licensed nurse) took Resident #1 and other resident medications, including narcotic medications, for RP2_x001A_s personal use for more than a year. The facility failure to protect residents from RP2's theft of medications, including narcotic medication, is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +OR0000978600,385197,NF,6/30/2015,Evidence and interviews indicated facility failure to adequately assess Resident #5's pain and neurological status related to an unwitnessed fall on 6/29/2015. Facility failure to ensure Resident #5's pain and neurological status was adequately assessed after the fall placed Resident #5 at risk for an undetected change of condition. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000984000,385197,NF,7/29/2015,"Evidence and interviews indicated facility failure to follow the care plan for fall prevention for Resident #2. The facility failure to ensure care plan interventions were in place resulting in Resident #2 sustaining a right hip fracture are violations of resident rights, are considered neglect of care, and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000992700,385197,NF,8/13/2015,"Evidence and interviews indicated facility failure to adequately assess and monitor Resident #1's pain and neurological status after Resident #1 sustained a 7/31/2015 unwitnessed fall. Resident #1 indicated she/he was given her/his ""regular"" chronic pain medication after the fall, however the pain pill, ""I always took did not touch the pain."" The facility failure to ensure adequate care and services related to Resident #1's change in condition, resulting in Resident #1 sustaining ongoing pain, are violations of resident rights, are considered neglect of care, and constitute abuse. Relevant portions of the complaint report investigation are attached.",2,250,Substantiated,Substantiated,Neglect +MS152601,385197,NF,8/26/2015,"Evidence and interviews indicated facility failure to adequately care plan for Resident #1 regarding Resident #1's fractured hip. An in room care plan for Resident #1 dated 7/28/2015 indicated Resident #1 required extensive assistance with 2+ people for bed mobility. The 7/28/2015 in room care plan also indicated Resident #1 had a right hip fracture and she/he should only be turned on her/his left side. On or about 8/26/2015 RP2 (CNA) assisted Resident #1 with bed mobility and incontinence care. RP2 turned Resident #1 onto her/his right side causing Resident #1 to yell out in pain. In addition, witness #5 (licensed nurse) indicated Resident #1 was left wet (incontinent) for at least two hours. The Facility failure to ensure adequate care and services for Resident #1 resulting in Resident #1 sustaining unreasonable discomfort, is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MS153432A,385197,NF,11/5/2015,Evidence and interviews indicated facility failure to provide Resident #2 adequate care and services related to 11/4/2015 circumstances where Resident #2 requested assistance approximately 18 to 20 times during night shift. Evidence and interviews failed to indicate facility staff provided adequate assessment and follow-up regarding Resident #2's requesting commode assistance 10 to 12 times and after voiding only three to four times during night shift on or about 11/4/2015.,2,,Not Substantiated,Substantiated, +MS153432B,385197,NF,11/5/2015,Evidence and interviews failed to indicate facility failure to protect Resident #1 from rough treatment on or about 11/4/2015.,0,,Not Substantiated,Substantiated,Physical Abuse +MM105949,385199,NF,11/9/2010,"According to witness #3 (CNA) Resident #1 had long hair that was almost to Resident #1_x001A_s _x001A_rear._x001A_ Resident #1_x001A_s family member said on November 7, 2010 she/he observed Resident #1_x001A_s hair was cut off. Witness #1 and witness #8 said between Saturday and Sunday morning someone cut off Resident #1_x001A_s braid. A facility incident report dated November 7, 2010 indicated Resident#1 and her/his family were upset Resident #1_x001A_s long hair had been cut short without consent.",3,400,Substantiated,Substantiated,Neglect +OR0000683800,385199,NF,4/18/2011,"Based on interviews and documentation, it was determined the facility failed to thoroughly investigate a fall sustained by Resident #1 on 4/9/2011. Based on interviews and documentation, it was determined the facility failed to contact a physician in a timely manner after Resident #1 sustained a fall with injury on 4/9/2011. Based on interviews and record review, it was determined the facility failed to follow Resident #1's care plan on 4/9/2011. Relevant portions of the survey report are attached; federal civil penalty recommended.",3,0,Substantiated,Substantiated,Neglect +MM116969,385199,NF,4/27/2011,"Resident #1_x001A_s care plan specified she/he required escorts to meals and activities, was unable to make needs known and had impaired decision making ability. On 4/27/2011 facility staff failed to ensure an escort for Resident #1_x001A_s ordered medical test. Resident #1 arrived at the appointment alone and was unable to have the ordered test.",3,250,Not Substantiated,Substantiated, +MM146806,385199,NF,4/15/2014,Evidence and interviews indicated facility failure to provide Resident #1 a secure environment related to an in incident on 4/15/2014 where Resident #1 exited the building without assistance.,2,,Not Substantiated,Substantiated, +MM146759,385199,NF,4/10/2014,Evidence and interviews indicated facility failure to provide Resident #1 a safe environment. On 04/10/2014 RP2 (staff) left a bottle of cleaning fluid on a table and Resident #1 potentially ingested some cleaning fluid. This failure placed Resident #1 at risk for harm and was a violation of Oregon Administrative licensing rules.,2,,Not Substantiated,Substantiated, +OR0000876000,385199,NF,2/5/2014,"Evidence and interviews indicated facility failure to ensure Resident #1 received two-person transfer assistance according to her/his care plan. Facility failure to ensure Resident #1 a safe environment resulting in Resident #1 sustaining a fractured knee during a transfer are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +MM146748,385199,NF,4/2/2014,Evidence and interviews indicated facility failure to provide Resident #1 and Resident #2 a safe environment when failing to provide timely interventions for a resident-to-resident altercation on 04/02/2014. Resident #1 and Resident #2 had no reported injuries resulting from the incident. This was the second resident-to-resident (non-injury) altercation between Resident #1 and Resident #2; the first incident occurred on 03/03/2014.,2,,Not Substantiated,Substantiated, +MM147487,385199,NF,6/21/2014,"Evidence and interviews indicated facility failure to adequately intervene with Resident #1's known sexual behaviors. Resident #1's June 2014 care plan indicated she/he had a history of inappropriate sexual behavior and Resident #1 was supposed to be supervised by staff when in a common area. On 6/21/2014, Resident #1 was left alone with other residents and during that time Resident #1 inappropriately fondled Resident #2's chest. The facility failed to protect Resident #2 and Resident #1 from inappropriate sexual contact are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Sexual abuse +MM148959,385199,NF,10/13/2014,"Evidence and interviews indicated facility failure to adequately intervene with Resident #1's known behavior related to circumstances where Resident #1 was found unbuttoning Resident#2's blouse in while she/he was asleep in a common area of the facility. The facility failure to adequately address and intervene with Resident #1's known behaviors toward other resident's is a violation of resident rights, considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MM149042,385199,NF,10/17/2014,"Evidence and interviews indicated facility failure to provide adequate interventions regarding Resident #1_x001A_s known inappropriate behaviors. On October 23, 2014, witness #1 walked into Resident #2_x001A_s room and found Resident #1 reaching her/his hands under the blankets of Resident #2_x001A_s bed touching Resident #2. The Facility failure to provide adequate interventions with Resident #1_x001A_s behavior resulting in Resident #1_x001A_s behavior escalating and negatively affecting Resident #2 is a violation of resident rights are considered neglect of care and constitutes abuse.",2,300,Substantiated,Substantiated,Neglect +MM148033,385199,NF,7/28/2014,Evidence and interviews indicated facility failure to provide a secure environment for Resident #1 related to circumstances on 7/27 and 7/28/2014 where Resident #1 left the facility via the front doors without assistance.,2,,Not Substantiated,Substantiated, +MM159994,385199,NF,1/19/2015,Evidence and interviews indicated facility failure to provide a safe environment and adequately address interventions for Resident #2's known behaviors toward other residents. On or about 1/19/2015 Resident #2 slapped Resident #1 across her/his stomach and leg. There were no reported injuries to either Resident because of the 1/19/2015 incident between Resident #1 and Resident #2. Resident #2 had one prior incident of behaviors toward another resident.,2,,Not Substantiated,Substantiated, +OR0000980203,385199,NF,7/10/2015,Evidence and interviews indicated the facility failed to follow their Policy and Procedure for investigating falls for Resident #1 who sustained falls on 7/3 and 7/5/2015. The facility failure to follow their Policy and Procedure for fall investigations placed Resident #1 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000985500,385199,NF,7/30/2015,"Evidence and interviews indicated the facility failed to ensure a safe environment related to ensuring the care plan was followed for Resident #2 who required bed mobility assistance. The failure to provide the necessary care planned assistance with bed mobility resulted in Resident #2 rolling off the bed to the floor. The facility failure to provide adequate care and safety services, resulting in Resident #2 sustaining an assisted fall and _x001A_coccyx strain_x001A_ is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,300,Substantiated,Substantiated,Neglect +OR0000985501,385199,NF,7/30/2015,Evidence and interviews indicated facility failure to follow physician orders for administration of Resident #2's pain medication. The failure to administer Resident #2's pain medication per physician orders placed Resident #2 at risk for adverse effects from the medication. Relevant portions of the complaint report are attached.,2,,Not Substantiated,Substantiated, +MM151652,385199,NF,6/12/2015,"Evidence and interviews indicated facility failure to provide a secure environment and failure to maintain a functional alarm system when Resident #1 exited the building and fell in the parking lot. Resident #1 had initial complaints of pain after the fall, however evidence and interviews failed to indicate Resident #1 sustained injury because of her/his fall.",2,,Not Substantiated,Substantiated, +MM151667,385199,NF,6/21/2015,Evidence and interviews failed to indicate facility failure to provide an adequate medication administration system related to circumstances on or about 6/21/2015 when Resident #1's family member took Resident #1 out of the facility before morning medications had been given. Resident #1's medication administration record indicated she/he was administered all ordered medications on 6/21/2015.,0,,Substantiated,Not Substantiated, +OR0001013600,385199,NF,10/8/2015,Evidence and interviews indicated facility failure to complete thorough investigations of incidents for Resident #2 and Resident #4. Facility failure to complete thorough investigations put Resident #2 and Resident #4 at risk for potentially unaddressed abuse and neglect. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001024500,385199,NF,11/3/2015,"Evidence and interviews indicated the facility failure to complete thorough investigations for Resident #2 and Resident #4. This failure put Resident #2 and Resident #4 at risk for potentially unaddressed abuse and neglect. Evidence and interviews indicated facility failure to conduct timely assessments of non-pressure ulcers for Resident #2 and Resident #8, #9, #10, and #12. Facility failure to conduct timely assessment of Resident #2 and other afore-mentioned residents placed residents at risk for unmet needs. In addition, evidence and interviews indicated facility failure to ensure certified nursing assistant (CNA) staff demonstrated competency and understanding in implementing Resident #2_x001A_s care plan. This failure placed Resident #2 at risk for avoidable injuries and accidents. Relevant portions of the complaint report investigation are attached.",2,650,Not Substantiated,Substantiated, +OR0000719700,385200,NF,10/5/2011,"Resident 1 was admitted September 2011 with multiple diagnoses. The care plan noted a history of falls with intervention including use of a walker for independent ambulation. On 10/4/11 Resident 1 sustained an unwitnessed fall in the facility dining room and was transferred to the ER. Resident 1 sustained a fractured pelvis and finger along with a minor head injury. Staff 2 reported asking Resident 1 and another resident if they wanted dinner, but did not observe them walking to the dining room. Staff 2 was not in the dining room at the time Resident 1 fell. Staff 2 was busy with a resident's admission and unable to ensure adequate supervision of the residents at the time of the incident. Relevant portions of the survey are attached. A civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +PT118694,385201,NF,12/10/2011,Evidence and interviews indicated Resident #1 was injured while receiving transfer assistance from a recliner to a wheel chair on 12/10/2011. Resident #1's in room care plan indicated staff should use a sit-stand lift with transfers. The care plan also indicated Resident #1 required one person transfer assistance. RP2 (CNA) assisted Resident #1 with transferring using a gait belt. While Resident #1 stood to pivot her/his leg slipped and Resident #1's leg hit the wheelchair. Resident #1 sustained a right leg laceration after hitting the wheel chair leg pin post.,2,0,Substantiated,Substantiated,Neglect +PT129268B,385201,NF,12/23/2011,Evidence and interviews indicated facility staff failed to provide Resident #1 with timely toileting assistance on 12/23/2011. Resident #1 attempted to use the garbage can for toileting and she/he fell on the floor as a result of this incident. Evidence and interviews failed to indicate Resident #1 sustained injury as a result of the un-witnessed fall on 12/23/2011.,2,0,Not Substantiated,Substantiated, +PT129603,385201,NF,3/18/2012,Evidence and interviews indicated facility failed to properly plan Resident #1's care resulting in Resident #1 sustaining blisters on her/his left wrist and forearm.,2,300,Substantiated,Substantiated,Neglect +PT129891,385201,NF,3/12/2012,Evidence and interviews indicated facility failure to provide Resident #2 adequate toileting assistance resulting in Resident #1 sustaining a sore bottom after sitting and waiting for transfer assistance for an hour. Evidence and interviews indicated Resident #1 and Resident #2 did not receive bathing assistance as care planned.,2,0,Substantiated,Substantiated,Neglect +PT120120,385201,NF,5/21/2012,Evidence and interviews indicated facility failure to ensure Resident #1 received adequate toileting assistance on 05/21/2012 resulting in Resident #1 sustaining an episode of incontinence and becoming embarrassed and humiliated.,2,250,Substantiated,Substantiated,Neglect +OR0000817000,385201,NF,3/8/2013,Evidence and interviews indicated facility failure to provide adequate monitoring and services coordination for Resident #1 who experienced changes related to a pressure ulcer. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000831300,385201,NF,5/23/2013,Evidence and interviews indicated facility failure to ensure that two CNA staff (staff #3 and staff #6) promptly reported Resident #1's fall to nursing. Resident #1 experienced delayed treatment of a fracture and increased pain. This failure is considered neglect of care and constitutes abuse. Federal penalty recommended; relevant portions of the complaint report investigation are attached.,3,,Substantiated,Substantiated,Neglect +PT146468,385201,NF,3/17/2014,Evidence and interviews indicated facility failure to protect Resident #1 from an unknown person taking $100 from Resident #1's wallet on or about 3/19/2014. The facility failure to ensure lockable storage for money and/or valuables to protect Resident #1 from the theft of $100 is considered financial exploitation and constitutes abuse.,2,,Substantiated,Substantiated,Financial abuse +PT148207B,385201,NF,8/18/2014,Evidence and interviews indicated facility failure to ensure RP2 (CNA) followed Resident #1's care plan. Resident #1 was care planned for two-person assistance for all care needs. On or about 08/18/2014 RP2 disregarded Resident #1's care plan while providing one-person assistance to reposition Resident #1 in her/his bed.,2,,Not Substantiated,Substantiated, +OR0000903201,385201,NF,6/19/2014,"Evidence and interviews failed to indicate facility failure to provide Resident #1 the necessary care and services related to skin breakdown. However, as a result of the investigation other concerns were identified in the expanded resident sample for Resident #4. Evidence and interviews indicated the facility failed to obtain physician orders and ensure treatment was provided as ordered for Resident #4 who was reviewed for pressure ulcers. Resident #4 was at risk of complications related to pressure ulcers. The facility failure to ensure adequate treatment of Resident #4's skin breakdown resulting in Resident #4's worsening is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000911400,385201,NF,7/28/2014,"Based on evidence and interviews it was determined the facility failed to ensure nursing was notified after Resident #2 sustained a fall, sustaining a fractured hip. Facility failure to ensure adequate assessment and intervention after Resident #2_x001A_s fall is a violation of resident rights, considered neglect of care and constitutes abuse. + + + +Based on evidence and interviews it was determined the facility failed to obtain physician orders and ensure treatment was provided for Resident #4_x001A_s pressure ulcers. Facility failure to provide adequate treatment for Resident #4_x001A_s pressure ulcers is a violation of resident rights, considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,700,Substantiated,Substantiated,Neglect +PT149052,385201,NF,8/29/2014,"Evidence and interviews indicated facility failure to assure resident rights related to circumstances on 08/29/2014 where RP2 (CNA) shined a flashlight in Resident #1's face while providing care. RP2 told Resident #1 to quit using the call light and RP2 told Resident #1 that she/he was ""pissing [RP2] off.""",2,,Not Substantiated,Substantiated, +PT148893,385201,NF,10/7/2014,Evidence and interviews indicated facility failure to protect residents from inappropriate sexual contact related to circumstances on 10/72014 between Resident #1 and Resident #2. Resident #2 groped Resident #1 while the residents were sitting together in a hallway. Resident #2 is care-planned for a history of inappropriate sexual behaviors The Facility failure to provide adequate interventions with Resident #2's behavior resulting in Resident #2's behavior escalating and negatively affecting Resident #1 is a violation of resident rights are considered neglect of care and constitutes abuse.,2,,Substantiated,Substantiated,Neglect +OR0000930601,385201,NF,10/31/2014,Evidence and interviews indicated facility failure to ensure that discharge orders were reflective for all current treatment prior to Resident #3's discharge. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000929900,385201,NF,10/29/2014,Evidence and interviews indicated Resident #3 sustained a 10/29/2014 fall as a result of inadequate transfer assistance provided by Staff #19 (CNA). Staff #19 said she/he failed to follow Resident #3's care plan when attempting to transfer Resident #3 from the wheelchair to the bed. Staff #19 lowered Resident #3 to the floor when unable to complete the transfer and Resident #3 sustained a small bruise to her/his buttocks.,2,,Not Substantiated,Substantiated, +PT151354,385201,NF,4/1/2015,Evidence and interviews indicated facility failure to protect Resident #1 from an unknown person taking $250 from Resident #1's wallet on or about 4/1/2015. The facility failure to ensure lockable storage for money and/or valuables to protect Resident #1 from the theft of $250 is considered financial exploitation and constitutes abuse.,2,,Substantiated,Substantiated,Financial abuse +PT151355,385201,NF,5/1/2015,"Evidence and interviews indicated facility failure to provide Resident #1 and Resident #4 adequate care and services related to showering and toileting assistance. Evidence and interviews indicated facility failure to provide Resident #6 and other facility residents adequate call light assistance. Facility failure to provide Resident #1 and Resident #4 adequate care and services related to showering and toileting assistance are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000972501,385201,NF,5/26/2015,"Evidence and interviews indicated the facility failed to follow physician orders for Resident #5_x001A_s physician order for a nutritional supplement and failed to ensure accurate weights were maintained. On 3/19/2015, the facility recorded Resident #5_x001A_s weight as 141 pounds. On 3/25/2015, the facility recorded the resident_x001A_s weight as 126.2 pounds. There was no documented reweigh of Resident #5 to ensure accuracy nor was there an assessment of possible causes for the 15-pound weight loss. Evidence and interviews indicated the facility failed provide Resident #5 a physician ordered nutritional supplement between 4/1/15 through 4/22/2015. Facility failure to follow physician orders for Resident #5_x001A_s nutritional supplement, and failure to adequately assess and monitor Resident #5_x001A_s unplanned weight loss is a violation of resident rights, considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,400,Substantiated,Substantiated,Neglect +PT153352,385201,NF,10/12/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate hygiene assistance. Resident #1 received care at the hospital emergency room on or about 10/12/2015. Witness #2 said Resident #1_x001A_s clothing and sling were saturated with urine, there was a strong smell of urine, and Resident #1 had not received peri-care assistance after sitting in urine soaked undergarments for _x001A_hours_x001A_. The facility failure to provide Resident #1 with adequate hygiene assistance, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +PT153642,385201,NF,10/14/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate incontinence care resulting in Resident #1 sitting in feces for an hour on at least one occasion. Facility failure to provide Resident #1 adequate incontinence care are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +PT164133,385201,NF,8/15/2015,"Evidence and interviews indicated facility failure to adequately protect Resident #1 from the theft of Resident #1_x001A_s jewelry. Law enforcement reports indicated an estimated value of $3,000 to $4,000 related to Resident #1_x001A_s stolen jewelry. In addition, evidence and interviews failed to indicate the facility conducted an adequate internal investigation regarding the reported theft of Resident #1_x001A_s rings also failing to notify law enforcement and the Division regarding the loss of Resident #1_x001A_s jewelry. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining a loss of personal property is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,450,Substantiated,Substantiated,Financial abuse +PT164952A,385201,NF,2/27/2016,"Evidence and interviews indicated facility failure to provide a safe medication system related to circumstances on or about 2/26/2016 when RP2 (CMA) incorrectly administered Resident #1 blood pressure medication and Tylenol, prescribed for a different Resident.",2,,Not Substantiated,Substantiated, +OR0000764701,385203,NF,6/4/2012,Evidence and interviews indicated the facility failed to provide Resident #1 adequate catheter care and services resulting in Resident #1 sustaining unreasonable discomfort. Relevant portions of the survey complaint are attached.,3,400,Substantiated,Substantiated,Neglect +OR0000784300,385203,NF,9/17/2012,Evidence and interviews indicated facility failure to ensure Resident #1's admission insulin orders were transcribed and implemented properly resulting in Resident #1 requiring hospital evaluation. Relevant portions of the complaint report survey are attached.,3,450,Substantiated,Substantiated,Neglect +OR0000781002,385203,NF,8/31/2012,Evidence and interviews indicated facility failure to timely report an incident involving Resident #1. Resident #1 sustained bruising that was not timely assessed or investigated. Relevant portions of the complaint report investigation are attached.,0,0,Substantiated,Substantiated,Neglect +OR0000781004,385203,NF,8/31/2012,Evidence and interviews indicated facility failed to provide Resident #1 adequate care and services related to scheduling transportation to medical appointments. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +OR0000814800,385203,NF,2/28/2013,The facility failed to provide Resident #1 adequate care and services regarding a 12/23/2012 change of condition. The facility failure to provide Resident #1 adequate care and services regarding a change of condition resulted in hospital treatment. This failure is considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.,3,500,Substantiated,Substantiated,Neglect +OR0000822000,385203,NF,4/4/2013,The facility failed to provide Resident #1 adequate care and services regarding a significant change of condition on 04/01/2013. The facility failure to provide Resident #1 adequate assessment and monitoring regarding a significant change of condition resulted in hospital treatment. Relevant portions of the complaint report investigation are attached.,3,450,Substantiated,Substantiated,Neglect +OR0000831002,385203,NF,5/20/2013,"Evidence and interviews indicated facility failure to provide Resident #1, bowel care according to physician orders resulting in Resident #1 resulting in Resident #1 experiencing a change in condition, pain and hospital treatment related to fecal impaction. In addition, evidence and interviews indicated facility failure to report neglect of care related to following bowel care physician orders for Resident #1. These failures are considered neglect of care and constitute abuse. Relevant portions of the complaint report investigation are attached, federal penalty recommended.",3,,Substantiated,Substantiated,Neglect +OR0000831003,385203,NF,5/20/2013,Evidence and interviews indicated facility failure to provide residents adequate care and services related to answering call lights in a timely manner. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000880400,385203,NF,2/28/2014,"Based on evidence and interviews it was determined Staff #2 (licensed nurse) failed to provide timely assessment and intervention with Resident #1_x001A_s change of condition. The failure to provide timely care and services placed Resident #1 at risk for unrecognized adverse health consequences. The facility failure to timely assess and intervene with Resident #1_x001A_s change of condition resulting in Resident #1_x001A_s hospitalization are violations of resident rights, are considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,300,Substantiated,Substantiated,Neglect +BH153601,385203,NF,4/27/2015,"Evidence and interviews indicated facility failure to provide a safe medication administration system protecting Resident #1, Resident #2, and Resident #3 from theft of medication by RP2 (CNA, CMA) who took at least 10 narcotic medications from residents on or about 4/27/2015. The facility failure to provide a safe medication administration system resulting in RP2_x001A_s theft of resident medications, is a violation of resident rights, is considered financial exploitation, and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +OR0000651001,385204,NF,12/1/2010,"Resident 1 was admitted 10-20-10 with multiple diagnoses including a right great toe amputation with a wound vacuum to the right foot. Resident 1 had an open area to the lower right knee. No documentation was a found regarding assessment of Resident 1's open area below the right knee after the initial assessment of 10/20/10. Resident 's right foot wound did not receive assessment between 10/7/10 and 11/16/10, except by the podiatrist on 11/10/10. A physician order of 11/16/10 ordered daily foot dressings, but the orders were not transcribed on the TAR and dressings were not completed as ordered. Between 11/1 and 11/28/10 there were no documented assessment s of Resident 1's right foot. The facility failed to routinely assess and provide physician treatments as ordered. Relevant portions of the survey are attached. A plan of corrections was submitted.",2,0,Not Substantiated,Substantiated, +HB116651,385204,NF,3/31/2011,"W5 spoke of prior resident to resident comments, but administrative staff were not aware of this. RV1's care plan did not address this behavior, but RV2's care plan addressed RV2's behavior with staff. RV2's care plan was not adjusted to provide safety for other residents allowing RV2's to approach and inappropriately fondle RV1's breasts. The facility notified law enforcement and adjusted RV2's care plan after this event.",2,0,Not Substantiated,Substantiated, +OR0000696100,385204,NF,6/27/2011,"Resident 1's physician ordered a ""warm pack to the neck PRN, but there was no assessment of care plan for the order."" Staff 3 reported being instructed by Staff 5 the A.M. of 6/25/11 to place a warm pack and then replaced the warm pack at between 1:40 P.M. and 1:50P.M. without reporting to Staff 5. Staff 5 reported being unaware of the warm pack placement in the afternoon. Staff 4 heard Resident 1 yelling help at 3:00 P.M., found Resident 1 without a call light in reach, observed Resident 1 with a red neck/ face and believed Staff 1 was aware. Staff 1 failed to report Resident 1's burned neck to Staff 6. Staff 6 applied a warm pack to Resident 1's neck at 3:40 P.M., but did not recall reporting to Staff 1. Staff 6 reported checking Resident 1 frequently and found the warm pack re-applied another time with Resident 1 refusing to have the pack removed. A friend of Resident 1 admitted applying the pack. Staff failed to follow facility policy/procedure regarding use of warm packs resulting in Resident 1's neck burn and autonomic dysreflexia. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000721100,385204,NF,10/13/2011,Staff 3 (RP2) failed to follow Resident 1's care plan resulting in Resident 1 falling to the floor; and sustaining a head and arm injury. RP2 acknowledged not following Resident 1's care plan to place Resident 1 in a highly visible area when Resident 1 was up in the wheel chair. Resident 1's care plan was up dated for further wheel chair safety. A directed in-service for staff was given 12/9/11. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000762800,385204,NF,5/22/2012,"Eight CNAs stated movement in bed included turning a resident. Staff 1 believed the resident's care plan was updated just one day prior to the incident and included use of two staff to assist the resident in bed. Staff 2 did not review the resident's kardex and believe "" bed mobility"" meant pulling the resident up in bed and getting the resident out of bed; not positioning the resident in bed. On 5/16/2012 Staff 2 turned the resident on his/her side and the resident rolled out of bed. Staff 3 reported the resident was used to bed rails at home and when turned at the facility the resident rolled out of bed grabbing for the rail and fell fracturing a rib. While staff did not follow the care plan at the time of the incident, evidence is insufficient to support Staff 2's through knowledge of what was meant by the care plan. The facility failed to explore what the resident was used to; bed rail for safety and support. Relevant portions of the survey are attached. A civil penalty was proposed. The facility failure represents an Oregon Administrative Rule violation.",3,0,Substantiated,Substantiated,Neglect +OR0000784400,385204,NF,9/18/2012,"The facility failed to properly assess, track and treat Resident 1's recurrent pressure ulcer. Resident was admitted with a Stage I pressure ulcer to the sacrum. Resident was sent to the hospital for an unrelated issue and staff at the hospital discovered the sacral ulcer and a Stage II to the right anterior sacral ulcer. Staff 3 reported nursing staff failed to notify resident's physician either the day of or the day prior to the hospitalization of the Stage II ulcer. Multiple staff ""assumed""' other staff had been treating the ulcer. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +OR0000796700,385204,NF,12/7/2012,"Resident 1 is a long term resident with multiple diagnoses including chronic kidney disease, hypertension and multiple cardiac surgical procedures. On 11/4/2012 resident sustained a change of condition, but resident's physician was not notified in a timely manner. The resident's POA was notified at 3:39 A.M. on 11/5/2012 regarding further decline and the resident was sent to the ER. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",1,0,Not Substantiated,Substantiated, +OR0000998700,385204,NF,9/1/2015,Resident 1 was admitted 1/2015 with multiple diagnoses as indicated in the investigation report. The resident care plan noted the resident received dialysis. Staff were to monitor the access site for bleeding or swelling after dialysis visits. The plan did not include monitoring the site for thrill or bruit. There was not documentation staff monitored the site. Relevant survey pages are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000698900,385206,NF,7/12/2011,"Resident 2 was assessed and care planned as a fall risk. Staff 5 (RP2) assisted Resident 1 to the toilet, returned to Resident 2's bedside to change the linen, observed Resident 2 stand and then fall before Staff 5 could intervene. Resident 2 sustained a fall with injury; a subsequent x-ray found a fractured left hip. Staff 5 acknowledged he/she knew Resident 2 was not to be left alone on the toilet. Staff 5 used very poor judgment in leaving Resident 2 alone on the toilet even though Staff 5 was just in the other room. Staff 5 was counseled regarding following a resident's care plan. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000764900,385206,NF,6/5/2012,"Resident 1 was admitted 2003 with multiple diagnoses including a stroke. The 1/9/2012 in room care plan directed staff to use a two person transfer using a slide board or sheet under resident's thighs. On 5/31/2012 staff heard a ""pop"" during the resident transfer when Staff 9 used a ""bear hug"" type one person transfer. Staff 7 observed the transfer, but was unable to stop the transfer at the time. Staff 4 was informed, assessed the resident and did not find evidence of injury. 24 hours later during Staff 4's next shift he/she observed a swollen and bruised arm. A subsequent x-ray revealed a fractured humerus. Evidences fails to directly link the non care planned transfer of 5/31/2012 to the fracture as no injury was discovered for 24 hours. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +OR0000786100,385206,NF,9/27/2012,"Resident 1 was a long term resident with diagnoses including stroke, flaccidity of the left side and some confusion. Resident's care plan indicated a two person transfer due to resident's flaccid left side and height according to Staff 2. On 9/21/2012 RP2 attempted a one person transfer and lowered the resident to the floor when the resident's ""knees"" buckled. RP2 failed to tell licensed staff or gain licensed staff assessment before moving the resident to a wheel chair. RP2 did not tell licensed staff of the fall until the afternoon of 9/24/2012. The resident sustained increased pain in the leg/hip beginning 9/22/2012 through 9/26/2012. Staff failed to document in the resident's nursing notes from 9/19/ through 9/23/2012, but did medicate the resident with Tylenol. Staff notified the resident's physician after learning of the fall on 9/24/2012 and x-rays were completed. The resident was sent to the ER on 9/26/2012 after the second set of x-rays confirmed a fracture. Further evidence reveals inadequate staffing to meet resident needs. The shift in question was extremely ""hectic"" with two staff providing care for 23 residents. Only one resident was relatively independent. Relevant portions of the survey are attached. A federal civil penalty was proposed. The facility failure was an Oregon Administrative Rule violation.",3,0,Not Substantiated,Substantiated,Neglect +AL132786A,385206,NF,11/6/2012,"W1 reported RV's medications are not given in a timely manner, i.e.. 8:00 A.M. medication are given at 9:30 to 9:40 A.M./ RV was unable to give relevant information. W4 reviewed a computerized medication log and there were ten times the medication was given later than 8:00 A.M. medication pass from 9/28/12 through 11/14/2012. Evidence fails to support negative outcome to RV, but potential for harm existed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +AL132786B,385206,NF,11/6/2012,"W1 reported RV's undergarments are not changed timely, RV is left in urine soaked garments and RV is not take out of bed ad care planned. W3 reported RV could be very wet within two hours and RV has some breakdown. W3 reported staff see family interacting with RV and do not want to interrupt, but staff received instruction to provide care even if family is with RV. RV's care plan addresses skin risk and intervention, but staff are not always following the care plan. Evidence was not sufficient to conclusively support staff failure to follow the care plan resulting in harm to RV. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000813300,385206,NF,2/25/2013,"Resident 1 was admitted late 2012 with multiple diagnoses including muscle weakness and dementia. A 2/15/2013 care plan indicated the resident was a fall risk with interventions including fall mats, low bed, not to be left unattended on the bed edge, bedside commode or on the toilet. A nursing note of 2/20/2012 indicated attempted self transfer at 1:19 P.M. and later rib pain. A subsequent x-ray revealed rib fractures. W1 left RV in the bathroom and stepped into the bedroom with resident out of sight/out of arm reach. W1 had worked with resident a lot and indicated he/she was familiar with the resident. W1 reported resident bathroom door was half opened, but then was closed by a student. W1 heard the resident fall. W1 reported making a stupid mistake and was trying to do too much. Staff 1 conducted a survey after this event and found staff definition of unattended required re-training and a revised care plan to be more specific rather than ""unattended"". Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +DA105830,385207,NF,10/4/2010,"From the beginning of RV facility stay staff attempted to have RV store his/her valuables in a safe within the facility. RV exercised his/her right to keep valuables in his/her room in a ""secret"" place. Facility staff believe the $100.00 in cash and the quarters were stolen in two separate incidents. There were no indications who might have taken the money. Family and staff searched for the money and were unsuccessful. Evidence is inconclusive whether or not the facility offered a locking drawer or other lockable device in RV's room with RV having the key to the device. The facility failed to provide a safe environment for RV's possessions; money.",2,0,Not Substantiated,Substantiated, +DA116787,385207,NF,4/2/2011,"The facility failed to ensure all care plan interventions to protect other residents from RV1's aggressive sexual behavior were consistently implemented. On 4/2/11 a motion detector on RV1's room door was not turned on; was found turned off by staff when staff noticed RV2 in RV1's room. At the time of the incident RV1 was guiding RV2's hand in the ""act of sexually stimulating RV1."" on 4/27/11 there were two separate events with RV1 and RV2; and then between RV1 and RV3. The only intervention was to separate the residents. The facility did not initiate any other interventions following the first incident on 4/27/11. The facility failed to provide a reasonably safe and secure environment for RV1, RV2 and RV3.",2,200,Substantiated,Substantiated,Neglect +OR0000690800,385207,NF,5/27/2011,"On 5/24/11 at 9:00 A.M. Resident 1 received another resident's medication in addition to his/her own medication. Staff 8 was orienting Staff 5, when Staff 8 was interrupted and stepped away. Staff 5 reported Staff 8 told him/her to give the medication to the resident in blue; both Resident 1 and the other resident were in blue. Staff 5 misunderstood which resident Staff 8 was referring to. Staff 5 had addressed Resident 1 who responded, but Staff 5 did not realize Resident 1 was cognitively impaired. Staff immediately notified Resident 1's physician, monitored Resident 1 and sent Resident 1 for further evaluation when the vital sign parameters changed. The facility provided in-service for all staff. Resident pictures have been added to the MAR. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000709100,385207,NF,8/18/2011,"Resident 1 was care planned for use of a gait belt, walker and stand by assist for ambulation. W1 was assisting Resident 1 without use of a gait belt when Resident 1's leg gave out and W1 lowered Resident 1 to the floor. Staff 4 reported Resident 1 would probably have fallen even if a gait belt was used. Resident 1 sustained a fracture. W1 knew Resident 1's care plan called for a gait belt, but Resident 1 had done well with out. Staff reported Resident 1 did not like the gait belt, but usually used it. Staff 4 reported staff were not informing the nurses or Staff 4 in situations where a resident refused the gait belt. All staff received further in-service. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000710400,385207,NF,8/23/2011,"Resident 2 was admitted 4/3/11 with multiple diagnoses and identified skin at risk. Care plan interventions included repositioning, skin assessments and pressure reducing measures. Resident 2's admission assessment noted multiple pressure ulcers and some bruising. As of 6/26/11 and 8/18/11 nursing notes showed frequent refusals to care and repositioning. On 8/19/11 a day shift CNA reported an open area to Resident 2's upper back; staff notified the physician. A pressure ulcer investigation believed the ulcer was due to ""bunched up linens."" the care plan was up dated to have staff seek other staff or the charge nurse when Resident 2 refused care. Staff 7 denied placing a bath blanket beneath Resident 2. Staff 5 reported finding the blanket beneath the resident and ""it looked straight."" staff 6 denied knowledge of the blanket beneath Resident 2; resident refused care. Staff 1 and 3 reported bath blankets were not usually left beneath a resident. The facility failed to ensure care and services to prevent new pressure sores from developing. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +DA129233,385207,NF,2/12/2012,"The complainant and W1 reported facility failure to ensure physician appointments for RV1 and RV2 were appropriately obtained. W3 reported RV2's problem was due to lack of communication between two physicians, but acknowledges failure to make an appointment for RV1 with in a prescribed time frame. RV1 and RV2 deny any problems with care. Staff were monitoring RV1's surgical site and deny any untoward surgical site issues. The events represent an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000807700,385207,NF,1/29/2013,"The facility failed to provide evaluation and assessment for safety of Resident 1's wheel chair, as well as, adequate supervision to prevent a fall from a wheel chair resulting in a fractured left fibula. The resident's care plan was up dated for safety after the injury fall. The facility failed to ensure the resident received a timely PT/OT evaluation after the physician wrote an order on 1/8/2013. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +DA132398,385207,NF,1/11/2013,"RV requires catheter care including changing the catheter every 5 days per W6. Witnesses reported checking the catheter and knew that decreased urine flow might indicate a clogged catheter soon. Staff normally would contact the physician if clogging occurred and receive instruction to flush the catheter. Staff notified RP1 on 1/10/13 of a catheter issue, but RP1 said it would have to wait. W3 reported being told by night shift the catheter had not worked properly and W3 told RP2 sho failed to promptly attend the catheter. RV was showing signs of agitation. While RV was unable to provide relevant information, a reasonable person would be uncomfortable with a full bladder. W9 denied being contacted about RV's catheter as RP3 recorded. RV's intake and output records were not complete. The facility failed on at least one occasion to provide adequate catheter care resulting in resident increase agitation. The failure resulted in minor harm with potential for moderate harm. An Oregon Administrative Rule was violated.",2,0,Substantiated,Substantiated,Neglect +OR0000818901,385207,NF,3/15/2013,"Resident 1 was admitted 7/2009 with multiple diagnoses. Resident's 10/2012 assessment identified memory problems, required assistance with mobility and skin at risk issues. The resident's care plan provided various interventions including pressure relieving devices, repositioning and weekly skin assessments. The weekly assessment dated 3/10/2013 noted an open buttock area identified on 3/9/2013 as a Stage II pressure area. The area resolved by 3/19/2013. The facility failed to notify the resident's responsible party of the pressure ulcer. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000818903,385207,NF,3/15/2013,"Resident 1 was admitted 7/2009 with multiple diagnoses. Resident's 10/2012 assessment identified memory problems, required assistance with mobility and skin at risk issues. The resident care plan of 4/5/2013 failed to reflect resident's wrapping the call light cord about his/her neck. The resident was at extreme risk for harm. On 4/9/2013 the resident call light was wrapped and taped out of the resident's reach. Staff 7 (LPN) stated the resident was found with the call light cord about hi/her neck, but no documentation was found. Staff 3 verified the care plan was not updated. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +MV133519,385207,NF,6/12/2013,"RV reported missing jewelry. RV was given options to secure his/her belongings. RV requested items be brought into the facility, but failed to notify staff of the items. Some staff knew of some items, but a valuables list was not maintained and or available for review. The facility did not fail to provide reasonable services to protect RV's personal possession, but did fail to document items staff knew about. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +DA134124,385207,NF,7/30/2013,"RV did not receive all pain medication as indicated in either RV's MAR or the Narcotic Count page. RV's MAR indicated RV was offered oxycodone every 8 hours, but often refused medication. The facility has no policy or procedure to reconcile resident MAR and the Narcotic Count page record. RV's pain medication disappeared without adequate documentation for the medication usage and or wasting of the medication. Evidence supports missing and or misappropriation of RV's medication which constitutes. An Oregon Administrative Rule violation occurred.",2,300,Substantiated,Substantiated,Financial abuse +DA134088,385207,NF,8/6/2013,RV was admitted on 07/30/2013 with multiple diagnoses including wounds to the coccyx area measuring 6 cm X 7 cm with a depth of .5 cm. RV's initial care plan failed to provide sufficient instruction for care regarding the coccyx wound. Some staff repositioned RV every two hours and others did not reposition RV when he/she was sleeping. Staff failed to obtain wound care orders in a timely manner or provide adequate pressure relieving measures. RV's wounds worsened by 08/13/2013 and measured 7 cm X 6 cm with a depth of 2.7 cm. RV's neglect of care constitutes abuse. Additionally staff failed to ensure physical therapy was incorporated into RV's care plan in a timely manner and or followed by staff resulting in staff applying splints without utilizing a schedule. RV was found at least one time without access to his/her call light. In general RV's care plan was inconsistent and haphazard placing RV in harms way. Oregon Administrative Rule violations occurred.,3,400,Substantiated,Substantiated,Neglect +DA120739,385207,NF,8/1/2012,"RP2 incorrectly loaded an inhaler, RV used the inhaler and inhaled the capsule filled with medication. RV reported it feels ""odd"", but it is not painful. RV's physician ordered a chest x-ray for which the facility paid. A follow-up physician note dated 8/9/2012 indicated ""no acute"" concerns. RP2 reported the inhaler was not one RP2 had seen before. RV was at risk for serious harm when inhaling the medication capsule into RV's lung. Following this event the facility provided further in-service for all licensed staff on all types of inhalers used at the facility, as well as, revised the facility policy/procedure for medication administration. The facility failed to ensure all staff were adequately trained to use all types of inhalers utilized at the facility. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",3,300,Substantiated,Substantiated,Neglect +OR0000850900,385207,NF,9/4/2013,"Resident 1 was admitted 8/15/13 with diagnoses including CVA and physician orders for two pain medications. The resident did not receive an initial pain assessment. Between 8/15 & 8/19/2013 the resident displayed symptoms of a UTI, consumed less fluids and symptoms of dehydration without assessment. The family took the resident to the clinic on 8//19/2013 and the resident was admitted to the hospital with diagnoses including Sepsis related to a UTI. The resident was re-admitted to the facility on 8/23/2013. the resident's intake and output from 8/23 to 8/29/2013 showed excessive output without evidence of assessment for dehydration, hypotension and UTI. Staff acknowledged lack of assessment. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000943000,385207,NF,1/5/2015,"Resident 1 was admitted 12/23/2014 with multiple diagnoses and an assessed need not be left alone while toileting due to a high fall risk. On 12/24/2014 at approximately 11:00 A.M. the resident was found on the floor with the resident reporting tripping over his/her socks. No investigation of the event or care plan changes were found. The facility failed to follow their own ""Event Management"" policy placing the resident at risk for future falls and risk for harm. Relevant survey pages are attached for review. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000968500,385207,NF,5/8/2015,"Resident 1 was admitted September 2014 with multiple diagnoses. W1 reported on 3/10/2015 the resident was at dialysis 1/2 hour, transported to the hospital, was in the ER for 1-1 1/2 hours and admitted when pressure ulcers to the buttocks were discovered. W1 denied any knowledge of ulcers prior to the resident's hospitalization. Record review and witness interview note resident history of skin break down, care/treatment and no actual open areas the week prior to the 2015 hospitalization. No concerns regarding Resident 1's care were identified, but two additional residents (2 & 3) record review revealed pressure ulcer concerns that were cited. Relevant survey pages are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +DA152996A,385207,NF,9/25/2015,RP2 took over the counter medication belonging to RV. RV did not sustain known negative physical effect from not receiving RV's medication when discharged. RP2 admitted to police as referenced in the police report DAP15001851 that RP2 took the medication from the facility return box without authorization. RP2's theft of RV's medication constitutes abuse. The facility failed to ensure an adequate medication system to prevent theft from the return box and has since changed the policy and procedure to using two staff for destroying/returning all medications. Oregon Administrative Rule violation occurred.,3,,Not Substantiated,Substantiated,Financial abuse +DA153930,385207,NF,10/11/2015,The facility failed to ensure an adequate medication system to account for narcotic medication given to residents. Multiple resident medications were signed out and or documented in various places without ensuring the resident actually received the narcotic medication. The facility failed to thoroughly investigate missing narcotic medication records placing residents at risk for receiving additional narcotic medication not ordered by their physician. There was also risk for resident medication being diverted for individual staff personal gain. The residents were placed at risk for harm. Oregon Administrative Rule violations occurred.,2,400,Inconclusive,Substantiated, +OR0000684400,385208,NF,4/21/2011,"Resident 1 was admitted April 18, 2011 with multiple diagnoses and assessed as dependent for transfer, dependent for hygiene and dependent for toileting. Resident 1's assessment indicated Resident 1 ""appears very weak ."" Resident 1's care plan required ""two person total assistance for entire process."" On April 19, 2011 at 8:20 P.M. Resident 1 was found on his/her room floor following Staff 1 placing Resident 1 on the commode and leaving Resident 1 unattended. Staff 1 did not recall what Resident 1's care plan said. Resident 1 sustained a preventable fall with head injury. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000740600,385208,NF,1/20/2012,Resident 46 was admitted 10/26/2011 with multiple diagnoses. Resident's fall care plan of 10/26/2011 identified fall risk; cognitive and mobility issues were identified. The physician orders included use of a soft helmet at all times. The resident air over lay mattress was adjusted to decrease resident sliding out of bed. The resident sustained 7 falls out of bed from 11/3/2011 through 12/3/2011. A 12/31/2011 fall assessment identified fall risks without care plan changes for safety. On 1/17/2012 staff removed resident's helmet for cleaning without direction to provide safety while the helmet was cleaned. Staff had checked resident 15 minutes before the resident fell to the floor. The resident sustained an injury that was located in an area the helmet would not have prevented. Resident's care plan was not followed at all times placing the resident at risk for harm. This failure resulted in a Oregon Administrative rule violation.,2,0,Not Substantiated,Substantiated, +OR0000795000,385208,NF,11/20/2012,"Resident 1 was admitted 3/13/2012 with diagnoses including a stroke. The nursing assessment indicated fall risk and the resident care plan revealed varied interventions. Resident 1 sustained falls with care plan changes after each fall. The resident sustained a non injury fall on 9/2/2012 during which time the resident had non-skid foot wear in place, but the mat was not in place. To help prevent a similar occurrence, house keeping was provided a list to help ensure mats were left in place. The facility violated an Oregon Adminstrative Rule.",2,0,Not Substantiated,Substantiated, +OR0000822100,385208,NF,4/3/2013,Resident 1 was admitted in 2010 with multiple diagnoses including dementia and diabetes. Resident_x001A_s smoking assessment of 3/22/2013 required supervision with smoking while using a smoking apron; and the facility was to store tobacco and fire material. Documentation and staff interviews indicated observed instances of the resident smoking without supervision or use of a smoking apron; resident refusal to use the smoking apron; staff checking for illicit smoking material only after the resident was out of the facility for several hours; and evidence of smoking materials in the resident_x001A_s room or on resident_x001A_s person. On 4/2/2013 a student nurse reported the resident _x001A_passed out_x001A_ during a transfer. Twenty minutes later staff heard calling and found the resident outside in flames. The resident was transferred to a burn hospital with second and third degree burns. Facility staff failed over several weeks to follow the resident smoking safety care plan; and or re-assess and provide new intervention when the resident would not allow staff to follow the care plan. The facility failure resulted in serious resident injury. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violations occurred.,4,2500,Substantiated,Substantiated,Neglect +BC133254,385208,NF,3/8/2013,"The facility failed to provide adequate training and or supervision resulting in a medication error with a negative outcome. RP2 gave RV medication in excess of what the physician ordered resulting in RV's blood pressure dropping; and RV reporting lethargy and ""over medicated feeling"". RP3(RN) failed to provide assessment and documentation regarding the event with RV. RP4(LPN) failed to thoroughly follow and or ensure documentation of the nurse practitioner's ordered vital signs placing RV at further risk for harm. The facility administration failed to investigate, document and report the negative outcome event. The facility implemented a new computer medication system without adequately training, supervising staff and or ensuring resident safety. The facility failure resulted in a negative resident outcome which constitutes abuse and Oregon Administrative Rule violations.",3,400,Substantiated,Substantiated,Neglect +BC164360,385208,NF,1/18/2016,"RP2 is a fairly new C.N.A. RP2 was trained to transfer RV without waiting and or using the sit to stand. RP2 reported transferring RV multiple times before and thought he/she could do it. RP2 did not want to wait for other staff to finish their breaks. RP2 reported being ""stupid"". RV sustained skin tears and received treatment. RV was unable to say how the wound occurred, but did say liking the facility and it is a good place. RP2 received further instruction and must sign a form each shift showing RP2 has read and understands resident care plans. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +JG104917,385211,NF,7/14/2010,On 7/14/2010 RP2 (CNA) was assisting Resident #1 and Resident #1 had incontinence. RP2 became frustrated with Resident #1; RP2 lost her/his temper and hit Resident #1 with a closed fist on the back of Resident #1's body.,2,0,Not Substantiated,Substantiated, +JG129753,385211,NF,12/7/2011,Evidence and interviews indicated facility failed to ensure Resident #1 received ordered insulin 12/07/2011 resulting in Resident #1 needing hospitalization.,3,400,Substantiated,Substantiated,Neglect +JG120221A,385211,NF,1/30/2012,Evidence and interviews indicated facility failure to ensure adequate medication administration for Resident #1 resulting in Resident #1 sustaining avoidable pain and discomfort.,3,400,Substantiated,Substantiated,Neglect +OR0000799900,385211,NF,12/24/2012,Evidence and interviews indicated facility failure to ensure Resident #1's care plan was followed regarding transfer assistance. Resident #1 experienced unreasonable pain after sustaining a fall on 12/20/2012. Enforcement action proposed. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000834100,385211,NF,6/7/2013,Evidence and interviews indicated facility failure to provide timely response and necessary care and services for Resident #1's injury of unknown origin. Evidence and interviews also indicated facility failure to ensure timely physician notification regarding new bruising to Resident #1's foot. Relevant portions of the complaint report investigation are attached.,2,300,Substantiated,Substantiated,Neglect +OR0000836200,385211,NF,6/14/2013,"Evidence and interviews indicated facility failure to ensure Resident #2 was administered narcotic pain medication as ordered. Resident #2 received 16 mg more Morphine than ordered on three occasions and required paramedic administration of Narcan to reverse the Morphine effects. These failures are considered neglect of care and constitute abuse. Federal penalty recommended, relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000836201,385211,NF,6/14/2013,"Evidence and interviews indicated facility failure to provide the necessary care and services related to Resident #2's medication administration. Resident #2 received 16 mg more Morphine than ordered on three occasions without adequate indication for it's use. These failures are considered neglect of care and constitute abuse. Relevant portions of the complaint report investigation are attached, federal penalty recommended.",3,,Substantiated,Substantiated,Neglect +JG132806B,385211,NF,4/1/2013,"When Resident #1 was admitted to the facility she/he was offered a lock box for valuables including $25 she/he had when admitted, however Resident #1 declined to use a lock box. Resident #1's $25.00 went missing or was taken by an unknown person. Resident #1 was reimbursed by the facility for the $25.00 reportedly stolen.",2,,Not Substantiated,Substantiated,Financial abuse +OR0000850801,385211,NF,9/4/2013,"Evidence and interviews indicated facility failure to administer Resident #6's anti-coagulation medication according to physician orders. In addition, Evidence and interviews indicated facility failure to assess resident's pain and other non-pharmacological interventions prior to the administration of an anti-anxiety medication for Resident #4, Resident #5 and Resident #7. In addition, evidence and interviews indicated facility failure to ensure an RN assessment of Resident #3's head injury after a fall with head injury on 09/05/2013 and failure to ensure emergency transportation to the hospital after Resident #3 experienced an acute change of condition placed Resident #3 at risk of serious harm. Relevant portions of the complaint report investigation are attached.",3,1300,Not Substantiated,Substantiated, +OR0000850803,385211,NF,9/4/2013,Evidence indicated Resident #3 sustained a fall with injury after falling and hitting her/his head on 09/05/2013. Evidence and interviews indicated the facility failed to thoroughly investigate the fall interventions for Resident #3 and determine the effectiveness. This failure placed Resident #3 at risk of serious harm; relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +JG135193,385211,NF,11/22/2013,"Evidence and interviews indicated facility failure to provide Resident #1 adequate incontinence and peri care. The facility failed to provide adequate incontinence and peri care resulting in Resident #1 sustaining reddened skin on her/his back and peri area. These failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,250,Substantiated,Substantiated,Neglect +OR0000867400,385211,NF,12/23/2013,"Evidence and interviews indicated facility failure to the necessary care and services to prevent skin breakdown for Resident #1 and Resident #3. The facility failed to provide adequate pressure ulcer treatment and services for Resident #1 and Resident #3 resulted in both residents experiencing pressure ulcers with a potential for wound status decline. These failures are violations of resident rights, are considered neglect of care and constitute abuse. Relevant portions of the complaint report investigation are attached.",2,400,Substantiated,Substantiated,Neglect +JG146432,385211,NF,3/20/2014,"Evidence and interviews indicated facility failure to ensure Resident #1 was administered pain medication as ordered. The Facility failure to ensure Resident #1 was administered pain medication as ordered resulting in Resident #1 sustaining continued pain and suffering are violations of resident rights, are considered neglect of care and constitutes abuse.",3,500,Substantiated,Substantiated,Neglect +JG134732,385211,NF,10/15/2013,"Evidence and interviews indicated facility failure to implement policy and procedure related to an incident where RP2 (CNA) was assisting Resident #1 in her/his wheelchair. Resident #1 bumped her/his toes against the door during a wheelchair transport by RP2 on or about 08/26/2013. Facility failure to ensure RP2 timely reported the incident placed Resident #1 at risk for discomfort. In addition, the same incident was investigated under complaint report investigation #OR00008508; relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +JG153505A,385211,NF,11/1/2015,"Evidence and interviews indicated facility failure to ensure Resident #1 was administered (5), 2mg of medication instead of (5), 1mg medications as ordered on or about 10/31/2015 resulting in Resident #1 sustaining a blood pressure change requiring monitoring until Resident #1's blood pressure returned to normal levels. The facility failure to administer Resident #1's medication as ordered, resulting in Resident #1 sustaining a change in blood pressure, requiring monitoring, is a violation of Oregon Administrative Rules.",2,,Substantiated,Substantiated, +OR0000654302,385212,NF,12/15/2010,Resident 3's September ADL record revealed Resident 3 did not receive a bath or shower as well as no bath/shower in parts of November 2010. Resident 3's October ADL sheet showed Resident 3 received two showers and refused showers. Staff reported Resident 3 often refused baths. Staff received further in-service about appropriate documentation. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000654600,385212,NF,12/15/2010,"Resident 2 was admitted November 2010 with diagnoses including a history of UTIs. A 12-6-12 urine test was positive for red/white cells, resident's physician was faxed, but no indication of a response was noted. Resident 2 was transferred to the ER on 12-12-10 with a reduced level of consciousness and diagnosed with urospesis. The facility failed to ensure Resident 2's physician was notified and orders obtained regarding Resident 2's abnormal labs. Resident 2's medical record review also noted that Resident 2 did not urinate on the evening and night of 12/11/10, but Resident 2 was not straight catheterized as ordered until 12/12/10 at 1:15 P.M. resulting in harm and hospitalization. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated, +NW104206,385212,NF,4/28/2010,"RV is cognitively impaired and at risk for elopement. RV had been observed pushing numbers on the exit keypad. The key code is posted above the door, was removed and new instructions placed after this event. It remains unknown if RV pushed the right code or followed a visitor out the door. RV was placed on 15 minute checks.",2,0,Not Substantiated,Substantiated, +OR0000682300,385214,NF,4/12/2011,"Resident 15 was admitted February 2010 with multiple diagnoses including a fractured femur, osteoporosis, etc. Resident 15 was assessed as requiring two people for transfer when Resident 15 was agitated or aggressive. Resident 15 was also care planned for use of a gait belt. On April 7, 2010 Staff 1 transferred Resident 15 alone without using a gait belt or the care planned two person transfer although Resident 15 was agitated. Staff 1 reported lowering Resident 15 to the floor has he/she lost his/her balance. Resident 15 sustained a fracture. Staff 1 Admitted not looking at Resident 15's care plan. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000683600,385214,NF,4/18/2011,Resident 13 was admitted October 2010 with multiple diagnoses. Resident 13 was assessed as a fall risk and care plan interventions included a bed alarm and bedside floor mat. On 4/13/10 at 3:45 P.M. Resident 13's alarm was sounding and staff found Resident 13 on the floor in front of his/her side table. The bedside mat was not in place; Resident 13 sustained a facial laceration. Staff 1 admitted forgetting the mat. The facility investigation found Resident 13 struck his/her head on the bedside table; the fall mat would not have prevented the injury. The facility provided further in-service to staff regarding following the care plan. The facility failed to provide a safe environment. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000800900,385214,NF,12/31/2012,"Staff noted a discrepancy in medication cards and returned the medication cards to the pharmacy. Resident 1 was identified as potentially effected by the tampered medication card. Review of Resident Mars and progressive notes from 11/20/2012 and 12/20/2012 found Resident 1 received scheduled and PRN pain medication with noted relief. The pharmacy replaced the medication cards and LEA, APS and OSBN were notified. A camera was placed in the medication room. Between 12/2012 and 1/2/2013 further audits, staff investigation, etc. found no additional tampered medication cards. Evidence supports theft of multiple resident narcotics which constitutes abuse and a Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Financial abuse +BC132971,385214,NF,3/5/2013,"The complainant reported items were taken from RV and not returned. Witnesses reported visitors (unknown) were in the facility prior to RV's discharge came back and requested RV's belongings. RV reported missing items and the facility stated they would reimburse, but RV declined the offer. The facility failed to ensure a safe environment resulting in RV's belongings to go missing. This failure constitutes abuse and a Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Financial abuse +HB117745A,385217,NF,8/10/2011,"Resident 1 was admitted to the facility on 08/10/11. The hospital faxed the facility the medication list with one page missing. As a result, resident 1 was without some medication for more than 24 hours, and suffered anxiety over not having his/her medication.",2,0,Not Substantiated,Substantiated, +OR0000819901,385217,NF,3/25/2013,Evidence and interviews indicated facility failure to inform Resident #1's family member of a change of condition. Facility failure left to adequately notify Resident #1's family members left the interested parties at risk for not being able to participate in decision regarding Resident #1's care. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated, +OR0000873600,385217,NF,1/16/2014,Evidence and interviews indicated facility failure to implement their policy for reporting and investigating a fall for Resident #4 who was at risk for injuries and continued falls. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +HB148240,385217,NF,8/22/2014,Evidence and interviews indicated facility failure to assure Resident #1's rights related to an incident on 08/21/2014 where RP2 (CNA) made inappropriate comments to Resident #1 about her/his personal possessions.,2,,Not Substantiated,Substantiated, +HB151272,385217,NF,5/14/2015,"Evidence and interviews indicated facility failure to assure adequate administration of Resident #1's narcotic pain medication resulting in Resident #1's pain continuing. The facility failure to assure Resident #1 adequate pain control resulting in Resident #1 sustaining untreated pain for several hours are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000720700,385218,NF,10/13/2011,"Resident 1 was admitted 9/1/11 with diagnoses including left hip fracture and dementia. Resident 1's assessment and care plan noted fall risk with interventions including non-skid foot wear and keep items in reach. Resident 1 fell on 9/20/11 while attempting a self transfer. Resident 1's care plan was updated 9/21/11 for alarm use. Resident 1 was found on the floor next to his/her bed on 10/9/11; no bed alarm in place. Resident 1 sustained a head laceration and required ER treatment. Resident 1's care plan was up dated. Staff 2 had questioned why the alarm was not on, but Staff 3 did not know. Multiple staff either failed to read Resident 1's care plan and or failed to ensure the plan was followed to ensure the alarm was in place. Not all falls are prevented by alarm use. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000746500,385218,NF,2/24/2012,"Resident 1 was admitted to the facility on 2/2/12 with diagnoses including a right hip fracture and macular degeneration. Resident 1's care plan initially indicated constant supervision with physical assist. A 2/17/12 P.T. progress note indicated minimal assistance for transfers and contact-guard-assistance for walking with a walker. Staff reported the resident did not fully appreciate his/her mobility limitations. Reviewer noted the O.T. POC mentioned resident was safe with personal hygiene in the bathroom, but the care plan was not updated. Staff 1 did not follow the written care plan, but left resident alone in the bathroom. The resident care and care planning may have been confusing for the care givers given the two different therapy notes. The facility failed to provide a safe environment for Resident 1 resulting in a injury fall. The facility assembled a fall team and further staff in-service was given. Relevant portions of the survey are attached. The incident represents a Oregon Rule Violation and a federal deficiency citation. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +BC116531,385219,NF,3/9/2011,"RP2 was loud with RV while in RV's room. RP2 was not to have contact with RV, but disregarded the nursing order. RP2 was counseled and will not provide care to RV.",2,0,Not Substantiated,Substantiated, +BC116728,385219,NF,4/9/2011,RV has not received all skin care treatment as ordered. Facility documentation failed to provide evidence as to why treatments were not always provided. RV was at risk for harm.,2,0,Not Substantiated,Substantiated, +OR0000689500,385219,NF,5/23/2011,"Resident 1 was admitted on 5/11/11 with multiple diagnoses. On 5/16/11 at 6:00 A.M. Staff 4's's progress notes show that Resident 1 had an episode of emesis on day shift and continued on night shift with a dark color ""coffee ground"" appearance. Staff 4 indicated Resident 1's physician was notified at 2:45 A.M. and new orders were received. The orders to continue monitoring Resident 1 during the early morning hours were not adequately followed. Staff 4 did not continue, as standard of practice would have, monitoring Resident 1's vital signs, call W3 (physician) when Resident 1 continued to have ""coffee ground"" emesis or notify Staff 1 and or Staff 2. Resident 1's family was not notified of Resident 1's vomiting until after 8:00 A.M. on 5/16/11. Staff 4 failed to notify Resident 1's family of Resident 1's change of condition in a timely manner. Review of Resident 1's MAR revealed Resident 1 did not receive all medication as ordered and Staff 3 failed to document this fact. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +BC118791,385219,NF,12/14/2011,"RP2 became busy and forgot to change RV's wet bed linen. RP2 did change the linen later. RV was upset, but did not sustain any notable physical effects. RV acknowledged it was possible RP2 forgot to come back promptly to change the linens. Evidence does not support RP2 ""yelling"" at RV.",2,0,Not Substantiated,Substantiated, +BC128834,385219,NF,12/13/2011,"Medication went missing from RV1 and RV2's medication storage site. W1 reported medications were kept in multiple sites including the medication cart, administration office and a lock box. Neither RV1 or RV2 sustained negative physical effects. All 6 residents involved in losing medication were assessed and none had unresolved pain issues. The facility took action to prevent a recurrence of lost medication. Lock and keys were changed, weekly audits were begun and new refill orders of monthly instead of 90 day supplies were begun. A call to the facility confirmed resident reimbursement for missing medication.",2,0,Substantiated,Substantiated,Financial abuse +BC120809,385219,NF,7/10/2012,"The facility failed to provide prompt intervention when the pharmacy called on 7/2/2012 reporting they sent Oxycodone and the medication was not changed in the book when it was received or when residents spoke with staff regarding they were not receiving their narcotic medication. Documentation review found narcotic cards as far back as January 2012 with RP2's signature as medication being wasted, but not the mandatory second signature. Resident record review found a pattern of RP2 giving narcotic medication to residents on RP2's shifts when the same residents did not require narcotics by other staff on other shifts. RP2 appeared glassy eyed and lethargic the morning of 7/1/2012 and later on 7/8/2012, but was allowed to stay and work; he/she became hysterical later in the shift on 7/8/2012. Multiple residents did not receive their medications in the A.M. of 7/8/2012. Residents reported at previous times not receiving their pain medication when the MAR showed that medication was given and initialed, but the initials were forged and or initialed by RP2 on days that RP2 did not work. The facility failed to ensure resident medication was secured and or properly given to residents at their request resulting in theft of resident medication by RP2 over an extended period of time. This failure constitutes abuse and represents an Oregon Administrative Rule violation.",3,400,Substantiated,Substantiated,Financial abuse +OR0000767400,385219,NF,6/14/2012,"Resident 1 was admitted 2011 with diagnoses including diabetes, reflux and nausea. On 6/5/2012 Resident 1 began a course of antibiotics with known side effects. A progress note of 6/62012 noted resident ""queezy"" but revealed antibiotics with out adverse effects. Beginning 6/8/2012 resident was requesting medication, not eating, small emesis reported and the physician was notified, but again the progress notes stated receiving antibiotics without adverse effects. The resident was examined by a physician on 6/11/2012, continued to complain of not feeling well and was sent to the ER on 6/13/2012, no facility documentation of resident's symptoms related to start of the antibiotic. Relevant portions of the survey are attached. Enforcement action was proposed. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +BC121067,385219,NF,7/23/2012,"RV1, RV2 and RV3 had checks taken and amounts written to and or cashed by RP2 in excess of $3866.00 during July 2012. Police documentation; bank photographs; RV1, RV2 and RV3 statements; and witness statements confirm checks were taken and written to RP2 by RP2 with out permission or knowledge of RV1, RV2 or RV3. RP2's actions constitute financial abuse of RV1, RV2 and RV3. The facility failed to provide a safe environment resulting in multiple thefts of checks and ultimately theft of resident resources from RV1, RV2 and RV3. This facility failure constitutes abuse and represents an Oregon Administrative Rule violation.",3,450,Substantiated,Substantiated,Financial abuse +BC132867,385219,NF,4/1/2013,"RV1, RV2 and RV3 were care planned for encouragement with ADLs and monitoring. RV1 and RV2 indicated having to wait for requested assistance and pain medication from RP2. RP2 admitted other staff were better with resident transfers. RV1 and RV2 did not sustain negative effect from less than timely delivery of care and or pain medication. RV1 and RV2 ""felt intimidated"". RV3 believed RP2 was less than ""straight forward"" with care. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000865301,385219,NF,12/2/2013,"Resident 63 was admitted September 2013 with multiple diagnoses. The resident transferred to the hospital for evaluation due to increased behavior. The resident was sent to the wrong hospital, a second cab was called and the resident was sent to the right hospital. The resident was at risk for harm. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000866700,385219,NF,12/12/2013,"Resident 5 was admitted 2005 with multiple diagnoses and an assessed risk for falls. The resident care plan indicated a one person transfer assist using a gait belt. Staff 5 reported not reviewing the care plan and not using a gait belt. Staff 5 reported the resident's foot moved, became off balanced and fell striking his/her face. The resident sustained an injury above the left eye. Failure to use the gait belt contributed to the resident's injury, but may not have prevented the fall. Staff 3 failed to report the injury fall due to misinterpretation of neglect of care. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +BC145906,385219,NF,1/21/2014,"The complainant reported RP2 forced the call light from RV's hands. RP2 reported asking multiple staff to assist with RV's care, but no one came to help. W1 reported misunderstanding what RP2 wanted and then went to assist RP2. RP2 reported only trying to get the call cord from RV and did not think he/she was being abusive. RP2 admitted not walking away and reapproaching as RP2 was trying to get RV to breakfast. RP2 used less than stellar standard of care while attempting to help RV. Evidence is insufficient to discern whether or not RP2 was rough or simply frustrated and rushing with care. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC145883,385219,NF,1/17/2014,RP2 removed RV's supra pubic catheter without an order. RP2 received an order to insert a urethral catheter and assumed no reason for RV to have two catheters in place. RV's supra pubic catheter had been non-functioning. Staff were unsuccessful in re-inserting the supra pubic catheter on 1/24/2014. RP2 received disciplinary action. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +BC145859,385219,NF,1/22/2014,RV received medication on 1/9 & 1/22/2013 that RV was not to receive. RV's physician and family were notified. W1 was upset and distrustful of the facility and RV was discharged a day early on 1/23/2014. RV denied any side effects from the medication given. The facility changed procedure so experienced RVs will more closely supervise staff. Staff received further in-service. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000916803,385219,NF,8/21/2014,"Resident 1 was admitted 8/17/2014 with multiple diagnoses including a fractured femur, weakness, depression, ataxia, vertigo, etc. as indicated in the attached report. Resident's care plan addressed resident's risks including wound care and fall risk. Resident had a surgical incision on the left femur with staples. The staples were removed and steri strips applied on 08/18/2014. The resident sustained a change in his/he urinary output on 08/19/2014 and the resident fell prior to staff being able to catheterize the resident; and the resident was sent to the hospital. Staff failed to notify the resident's family of the resident's hospitalization. The facility failed to have adequate documentation in the resident's medical record to ensure emergency telephone numbers and name were present. Relevant survey pages are attached. Regulatory enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC150220,385219,NF,1/17/2015,RV reported having $ 140.00 on Friday the day before RV went to ER. RV returned on 1/17/15 and the money was missing. RV reported leaving the wallet and money in his/her room while going to the ER. RV was missing $ 7.00 on 1/22/15. while the facility has cameras they were not directed toward RV's room at the time the $ 140.00 went missing. The facility failed to ensure a safe environment resulted in loss of RV's money. The facility reimbursed RV. RV is now receiving only $ 60.00 per month. The cameras are now focusing on RV's room.,2,,Substantiated,Substantiated,Financial abuse +BC150907,385219,NF,1/28/2015,"RV reported RP2 used a ""forceful and demanding"" tone toward RV; RP2 is rough and disrespectful. Witnesses were unable to say exactly what RP2 said to RV. W1 and 2 report RP2 can be rude and gruff with residents. W4 reported RP2 and another staff argued in the break room, but not in front of residents. W5 reported ""thinking RP2 became stressed in trying to get care givers to do their job', but doe not think RP2 is abusive. Preponderance of evidence fails to support abuse, but evidence does support RP2 being rude. Residents were not treated with all due respect. M Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +CO15131,385219,NF,6/25/2015,In review of the FMG Northeast Weidler Street Oregon LLC licensee application it was found that one applicant failed to meet all criteria required to meet approval as a new licensee. Specifically the applicant failed to have a record of good credit as evidenced by an OLRO credit check.,2,0,Not Substantiated,Substantiated, +BC164356,385219,NF,1/20/2016,"RV1was observed touching RV2 inappropriately. W2 was in the dining room with RV1 and RV2, but had turned their back while getting coffee ready. W1 observed RV1 touch RV2's neck; RV2 made a ""wincing face, indicating disgust or dislike. RV is non verbal and dependent on others for his/her care needs. RV1 had a previous inappropriate interaction with RV2 on 07/03/2015; RV2's care plan was adjusted on 10/08/2015 to monitor RV2 for safety. W2 observed RV1 and RV2 sitting together contrary to RV2's care plan of assisting RV to the dining room when RV2 is ready to be fed in order to maintain RV2's safety in the public area. Staff report RV1 sits on the opposite side of the dining room and must have wheeled self over to RV2. The facility failed to provide a safe environment resulting in RV2 receiving inappropriate touch by RV1. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000980800,385219,NF,7/14/2015,"Resident 2 was admitted to the facility from a local hospital on 7/9/2015 with multiple diagnoses and physician orders. Review of residents MAR revealed insulin and prednisone were given as ordered. Record review and staff interview indicate on 7/12/2015 at 10 P.M. the resident CBG was 81, snacks were given, CBG went to 103 and insulin was given with vital signs remaining stable. At 5 A.M. on 7/13/2015 staff found the resident unresponsive with a CBG of 32, glucose was given twice with the CBG going up to 44, but the resident remained unresponsive and the resident oxygen saturation was at 54. 911 was called and the resident was transferred to the ER. Staff report the resident received a snack and the CBG went to 100, but the resident did not request juice. There were no concerns regarding Resident 2's diabetic management. There were concerns found with the expanded sample residents (1and 3) as found in the CMS 2567, dated 1/25/2016 and F tag 309 was cited. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000980801,385219,NF,7/14/2015,"Resident 2 was admitted to the facility from a local hospital on 7/9/2015 with multiple diagnoses including noted deep sacral wounds and physician orders including a low loss air mattress. W1 reported the resident was in the facility four days, needed an air mattress and never got one. W1 reported W2 was with the resident until 10 P.M. and staff came in a couple of times, but family pretty much repositioned Resident 2. An equipment order dated 7/8/2015 with the word ""canceled"" across it was noted; unknown who canceled the air mattress or when it was canceled. The resident care guide of 7/9/2015 directed staff to assist the resident with turning and repositioning. Staff report the resident insurance did not impact orders for the air mattress. The resident discharged on 7/13/2015. It remains unknown when cancellation was written on the order form. Evidence does not support or deny Resident 2's wounds worsened. There were concerns found with the expanded sample resident 5 and 6 as found in the CMS 2567 dated 1/25/2016 and F314 was cited, Review notes Resident 5 was not reassessed for skin issues. Reviewer refers the reader to the 2567 regarding Resident 6's noted lack of documentation. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0001033400,385219,NF,11/30/2015,"Resident 12 was admitted to the facility in 2015 with multiple diagnoses including non-traumatic subdural hemorrhage, hemiplegia, paralytic syndrome, muscle weakness, anoxic brain damage and a history of a right wrist fracture. Record review and interview indicate the resident was found on the floor of his/her room on 11/23/2015 at approximately 12:00. At 1:28 P.M. resident's right hand was caught between the door and the wheel chair. On 11/25/2015 the resident sustained a change in condition to the right hand/wrist with a x-ray confirming a fractured wrist. Staff received further in-service and monitoring to ensure solutions are followed. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0001049301,385219,NF,1/11/2016,The facility failed to ensure timely repair of Resident 7's BiPAP mask. Resident 7 was at risk of complications from sleep Apnea. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0001050900,385219,NF,1/15/2016,"Resident 10 was admitted in 2015 with diagnoses including muscular dystrophy and muscle weakness. Per witness interview and record review the resident fell in his/her room on 1/11/2016 sustaining a lump/head injury and a severe sprain to the right ankle or a small fracture. The x-ray was negative for an obvious fracture. Staff 29 performed a one person transfer instead of a two person transfer and failed to utilize a gait belt. The resident placed the ""good leg"" on the scale and the other leg gave out. Staff 29 reported observing other staff transfer the resident with one staff and without use of the gait belt. Staff 29 failed to review resident's care plan prior to the transfer. All staff received re-in-service regarding care plan review. The facility failed to ensure a safe environment for the resident resulting in a fall with injury. Relevant portions of the suffer are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +AL105647,385220,NF,10/30/2010,"RV's physician ordered a non-narcotic pain medication 10-29-10, but RV did not receive the medication until 11/8/10 when W2 purchased the over the counter medication. RV's physician was notified of the incident and staff are providing one to one monitoring to be sure RV is not experiencing pain. RV exhibited negative behaviors before and during the time RV's medication was ordered and not given. The facility conducted an in-service concerning over the counter medication. The investigator observed RV smiling and with a pleasant demeanor.",2,0,Not Substantiated,Substantiated, +AL116116,385220,NF,1/9/2011,"RV left the facility approximately 6 months ago. The facility failed to sufficiently update the care plan after the elopement 6 months ago to help prevent the present elopement. To ensure RV's safety RV was placed on 15 minute checks and a wander guard was placed on RV's wheel chair after the recent elopement. While RV was not injured, RV was at risk for serious harm due to RV's cognitive impairment.",2,0,Not Substantiated,Substantiated, +OR0000687200,385220,NF,5/9/2011,"Resident 1 is a long term resident with diagnoses including hemiplegia and cognitive impairment with behaviors. Nursing notes of 5/7/11 revealed Resident 1 was found on the bedside crash mat without notable injury. Resident 1's bed alarm was not plugged in. Staff indicate Resident 1 is to have both bed and chair alarms. Staff 9 spoke with day shift staff who were ""sure"" the alarm was plugged in. Staff 9 spoke to all staff to make sure all staff were ensuring alarms were plugged in. Staff 7 failed to follow Resident 1's care plan for a two person transfer and fell with Resident 1. Resident 1 was not injured. Staff 7 reported other staff did not always use two people to transfer Resident 1. Staff received further instruction to follow the care plans. Relevant survey portions are attached.",2,0,Not Substantiated,Substantiated, +AL118192,385220,NF,3/16/2011,"W1 and RV reported RP2 entered RV's room unclothed and laid down on the bed next to RV. RV was receiving medication at the time that can cause hallucinations. W3 failed to promptly report the allegation. LEA investigation, as well as, facility and APS found no evidence to support the encounter as RV described. The facility staff failed to report the alleged sexual encounter as required. The facility failure to report is a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000712700,385220,NF,8/31/2011,"Resident 1 was admitted in last two months of 9/27/11 with diagnoses including scoliosis and recent lumbar surgery. Physician orders dated 8/15/11 required the TLSO be worn at all times when Resident 1 was out of bed. On 8/30/11 Staff 8 (RN) transferred Resident 1 to the bedside commode without the brace. Staff 8 reported Resident 1 stated he/she needed to use the commode ""right now."" A CNA transferred Resident 1 back to bed without realizing the brace was not in place. Staff 8 was in the room the whole time. Resident 1 was sent for evaluation and no injury was found. Orange signs were placed in Resident1's room as a reminder to always use the brace.",2,0,Not Substantiated,Substantiated, +AL129045,385220,NF,11/9/2011,On 11/9/2011 RV was examined at the ER and found to have a skin injury to the right fore arm that was steri stripped and healing well. The facility failed to document and or investigate the injury. All licensed nurses received further in-service on the importance of investigation and documentation of a wound. RV's care plan was updated to include monitoring extremities during transfers. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +AL128929,385220,NF,1/9/2012,Resident #1's care plan indicated she/he had a history of exit seeking. Evidence and interviews indicated Resident #1 exited the facility through the main door on 01/10/2012; the door alarm malfunctioned. W3 (facility staff) found Resident #1 outside of the facility about a block away. W3 escorted Resident #1 back to the facility where Resident #1 was assessed for injury and found to be unharmed.,2,0,Not Substantiated,Substantiated, +AL132905,385220,NF,1/20/2013,"W1 reported to staff that RV's complaint that ""family member"" hit him/her. The facility failed to report RV's complaint or discover how RV became injured. The facility failed to report an injury of unknown origin. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000815800,385220,NF,3/5/2013,"Resident 1 was admitted 2013 with multiple diagnoses. The resident admission profile did not identify pressure ulcers, but the 2/8/2013 care plan revealed skin at risk with multiple interventions noted. A 2/16/2013 incident and Unusual Occurrence sheet identified two pressure ulcers. Both ulcers were noted to have discolored skin around the ulcers. The February 2013 TAR and progress notes failed to contain wound descriptions. The weekly assessment for 2/23/2013 was not completed. The temporary care plan was discontinued and the resident plan of care was not updated on 2/28/2013. the resident was admitted to the hospital with a necrotic sacral wound. The facility failed to provide care and services to prevent pressure ulcers. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rules were violated.",3,0,Substantiated,Substantiated,Neglect +CO13123,385220,NF,9/11/2013,"Resident 103 developed 5 nonstageable pressure ulcers and 3 additional areas of suspected deep tissue injury to the resident's hand. Resident 103 was admitted on 8/23/2013 with lack of sensation to the left arm due to nerve damage, loss of movement and edema to the arm. Resident came in with a compression dressing to the arm. Resident's care plan failed to identify risk factors including compression dressing, edema and lack of sensation at the time the care plan identified risk for skin breakdown. Physical Therapy did their assessment and a physician progress note of 8/28/2013 noted the dressing was in place, but again nothing noting actual skin assessment beneath the dressing or interventions to address pressure ulcer development due to the above noted risk factors. On 9/4/2013 a physician order was obtained and included removing the dressing; provide skin care and hygiene; and rewrap the dressing. The physician order was transcribed to the TAR, but not implemented nor were there corresponding nursing notes to explain why the treatments were not carried out. Physical Therapy unwrapped the dressing on 9/11/2013 and the pressure ulcers were discovered. Facility staff failed to clarify whose responsibility it was to carry out the physician orders resulting in serious injury and harm to the resident. Oregon Administrative Rule violation occurred.",3,2500,Substantiated,Substantiated,Neglect +OR0000847000,385220,NF,8/19/2013,"Resident 2 was admitted 2007 and admitted to Hospice 6/13/2013. Resident's family was notified on 8/17/2013 at 8:30 A.M. of resident fall, but family was not notified of resident decline, nor given the opportunity, to decide if the resident should be evaluated at the hospital or given the opportunity to provide end of life spiritual comfort. Staff did notify Hospice, but failed to clarify who would notify family of resident's decline. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000863400,385220,NF,11/15/2013,"Resident 2 was admitted to the facility with multiple diagnoses including dysphagia. Resident's 10/29/2013 physician orders included a mechanical soft diet. The facility assessment and care plan indicated risk of resident retaining food in his/her mouth and difficulty swallowing. Specified care plan interventions included observing the resident at meal times and cuing the resident to swallow as needed. + + + +Review and interview indicated on November 13, 2013 at 6:10 P.M. the resident was eating too fast; staff encouraged resident to eat slower; resident began to ""throw up""; staff assisted the resident to his/her room; staff removed two whole chicken nuggets and soft food from the resident's mouth; and called EMS for assistance. EMS arrived and found the resident without a pulse; removed food from the resident's trachea; provided CPR for 15 minutes and transported the resident to the hospital; hospital arrival time was 6:50 P.M. + + + +The hospital record indicated the resident was without a pulse for 15 minutes, developed seizures after arrival, was extubated and died on 11/14/2013 at 8:00 A.M. The facility failed to provide and or ensure the resident received the physician ordered diet resulting in the resident choking, resident sustaining a change of condition, ie. Lack of a pulse; and resident transfer to the hospital for treatment. Facility failure to immediately request EMS service resulted in a delay of emergency treatment for Resident 2. The facility failures constitute neglect of care and abuse resulting in serious injury; and ultimately death. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,2500,Substantiated,Substantiated,Neglect +OR0000866600,385220,NF,12/12/2013,"Resident 1 was admitted November 2013 with diagnoses including a neck fracture, a Halo brace with vest, physician orders including to call the neuro surgeon for concerns. The orthotists instructions required daily skin examination under the vest. Documentation review did not reveal facility monitoring for pressure points under the Halo vest. A 12/5/2013 note by Staff 3 indicated resident complaint of pain by the Halo chest harness and medication given, but no indication of right chest skin assessment or physician notification. There were no progress notes on 12/6, 7 or 8/2013. A 12/9/2013 physical therapy note revealed resident complaint of pain, redness and a ""knot"" above the right clavicle. The resident sustained a Stage III pressure ulcer to the right upper chest. Multiple staff reported failure to check the resident's skin beneath the Halo vest. Staff 1 reported the facility did not have a policy for Halo brace care. The facility failed to provide adequate care and services resulting in serious harm which constitutes neglect and abuse. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred resulting in an enhanced civil penalty.",3,2500,Substantiated,Substantiated,Neglect +OR0000905401,385220,NF,6/27/2014,"Resident 1 was admitted May 2014 with multiple diagnoses. Resident' weight on 5/5/2014 was 236 pounds and 242 on 5/6/2014. On 5/12/2014 the resident weighed 219 pounds at the local hospital. Resident's physician ordered Lasix and a specific diet. The resident weight on re-admission to the facility was 218 pounds. Record review found the resident weight was up, there was edema of the lower extremities and lung sounds changes were noted. On 6/19/2014 the resident was anxious and calling out; the resident physician was not called regarding the weight gain. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000905402,385220,NF,6/27/2014,Resident 1 was admitted May 2014 with multiple diagnoses. Resident's 6/11/2014 OT assessment indicated 25% hands on assist stand pivot transfer. Staff recall a swivel rocking recliner in resident room. Staff 6 did not recall the recliner used the resident. The facility failed to ensure resident's environment remained free of accident hazards. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000924401,385220,NF,9/30/2014,Resident 81 was re-admitted to the facility on 9/14/2014. On 9/21/2014 at 11:23 P.M. the resident was diaphoretic and had a temperature of 101.5; the resident physician was not notified. On 9/22/2014 at 11:30 P.M. the resident temperature was elevated to 102.9; the physician was not notified. Resident's temperature was again up on 9/23/2014 at 11:30 P.M. without the physician being notified. Resident's physician was not notified of the temperature spikes until 9/24/2014 at 5:15 P.M. The resident sustained another increased temperature at 11:00 P.M. on 9/24/2014 and a fax was sent as indicated in a 2:30 P.M. note. Staff waited until 9/25/2014 at 2:30 P.M. to telephone the resident's physician and the resident was sent to the hospital. The resident was at risk for harm due to staff delay in not notifying resident's physician in a more timely manner. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000924403,385220,NF,9/30/2014,"Resident 81 was admitted in July 2014 with multiple diagnoses. Record review revealed the resident did not have informed consent for the use of anti-psychotic and anti-anxiety medication. Staff failed to adequately assess the resident for medications placing the resident at further risk of harm. Record review revealed the resident received several doses Ativan and Haldol without adequate re-assessment and care plan for non pharmacological interventions other than repositioning. Medication effectiveness was noted, but no reassessment to ensure the medication was still beneficial. The resident was at risk for harm. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000924405,385220,NF,9/30/2014,"Resident 81 was admitted to the facility in July 2014. the resident sustained a fall on 8/24/2014 without noted injury. Resident progress notes from 8/24/2014 through 8/31/2014 indicated the resident without latent injury from the fall. A weekly skin check of 8/27/2014 indicated the resident's skin was not intact; the TAR did not identify abnormal skin findings. A bruise was reported by the resident family on 9/3/2014, but the TAR had no documentation or monitoring in September. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000959101,385220,NF,3/30/2015,Resident 2 was admitted 2014 with multiple diagnoses including thyrotoxosis. The resident received Levothyroxine 125 mg instead of the ordered 175mg from 1/22/2015 to 2/10/2015. The resident was at risk for harm due to multiple days with a repeated medication error. Relevant portions of the survey are attached. Oregon Administrative Rule violations occurred.,2,200,Not Substantiated,Substantiated, +OR0000959102,385220,NF,3/30/2015,Resident 2 was admitted 2014 with diagnoses including a mental disorder and psychosis. The resident was discharged to the hospital on 3/22/2015 with behaviors. Staff failed to notify the resident's family until 3/23/2015. The facility failed to ensure the resident's rights were preserved by failing to notify the resident's family in a timely manner. Relevant portions of the survey are attached. Enforcement options were proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +AL151904,385220,NF,10/27/2014,"RV was found at the bedside on the floor; no fall mat was in place. RV sustained a bleeding head wound that did not require outside treatment. RV was unable to provide relevant information. RP2 denied responsibility for RV's injury and reported reading the care plan, but did not acknowledge whether or not RP2 placed the mat. RP2 failed to place RV's alarm and likely failed to place the fall mat. Evidence remains inconclusive if RP2's failure was due to simple human error or a miscommunication. RV sustained minor injury. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000983500,385220,NF,7/27/2015,"Resident 1 was re-admitted on 6/23/2015. the resident was able to direct his/her care. The resident received assessment and treatment, elected not to receive IVs, declined transport to the hospital and then agreed to transfer to the hospital. Resident 2 and Resident 3 were not thoroughly assessed and interventions were not timely initiated as a change of condition developed. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000983501,385220,NF,7/27/2015,"Resident 2 was re-admitted in 2014 with diagnoses including a stroke. The resident was assessed as a high risk for falls on 2/27/2015. the resident care plan was up dated on 4/28/2015 an May 2015 with further fall interventions. On 7/17/2015 the resident was found on the floor to the left of the fall mat. No incident report or staff interviews were completed regarding the 7/16/2015 fall. The resident was not thoroughly assessed after the fall. The resident developed distress, CPR was initiated and the resident was sent to the ER. The facility failed to provide adequate care and services related to Resident 2's fall. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000983502,385220,NF,7/27/2015,Resident 3 was re-admitted 2015 with diagnoses including diabetes. The resident 7/21/2015 discharge orders included specific CBG and Insulin orders with parameters when to notify the physician. The facility failed to implement all physician orders including parameters regarding CBG over 400 on four separate occasions. The resident was at risk for serious harm. The facility failed to provide necessary care and services regarding resident diabetes management. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +AL153166,385220,NF,9/18/2015,"Per interview and document review RV wheeled self out the front door. Staff believed a visitor held the door open for RV. RV's care plan was updated to 15 minute checks on the date RV eloped. RV sustained increased agitation, anxiety and received medication along with one to one supervision during the day shift, but no one to one supervision during the evening hours prior to RV's elopement. On 9/18/2015 a neighbor notified staff RV was outside in a neighbors drive way. RV was at risk for harm. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +MV164619,385220,NF,2/8/2016,"The complainant reported facility failure to clean and care for RV's colostomy/stoma resulting in the right side of RV's stomach being raw. RV reported facility failure to clean RV's room; it takes CNAs 2 to 3 hours to get to RV; staff see the light on and walk by; the acid burns RV's stomach all night; staff say there is nothing they can do; etc. W2 and W3 reported multiple concerns regarding RV's ostomy care and if directions were followed the site would get under control. W4, 5,,6 and 7 report being provided instruction, trying their own creations to get the wafer/bag to stay in place. W4 reported the bag is changed up to 9 times per day. W8 and 9 report visiting RV, observing the call light on, observed RV without a colostomy bag, a diaper around the site and RV's skin is worse than on admission. Per witness interview and documentation review the facility did not always follow ostomy cared orders including not using a Hollister 3 8331. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +AL152201,385220,NF,4/3/2015,"RV reported ""I felt"" [RP2] was being physically abusive, but RV described RP2 coming back 4 times and saying the same thing to RV. W1 reported observing RP2 raise hell of RP2's hand and hit RV's forehead, RV's head moved backwards, RV did not change expression or show reaction and came out of RV's room tearful. RP2 reported speaking to RV about behavior and RV's metabolic condition. RP2 reported placing a hand on RV's forehead while walking RV backwards; we were face to face. RP2 reported RV was smiling at RP2 and RP2 that touch response helps break mental activity; RP2 was trying to calm RV. RV's care plan does address RV's behaviors and RV received reassessment and new care plan interventions. Staff were counseled to report suspected abuse immediately and not to jump to conclusions. RP2 failed to follow RV's care plan at the time of the 4/3/2015 interaction. Evidence is inconclusive whether or not physical abuse occurred. Oregon administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +BH116262,385221,NF,5/9/2010,"The facility failed to protect RV1's right to not have his/her picture taken and or placed on a fund raiser calendar. W2 reported the facility mailed out consent forms for photos, but neither W3 or 5 received the form and staff failed to track who consented or did not consent.",2,0,Not Substantiated,Substantiated, +OR0000672303,385221,NF,2/28/2011,"Resident 1's Hospice assessment prior to his/her 2/24/11 admission did not include assessment of his/her skin. Resident 1 was admitted to the facility on 2/24/11 at 4:45 P.M. with comfort care orders. Resident 1 left on 2/26/11 at 12;30 P.M. Resident 1 was assessed on admission for high risk for pressure ulcers with identified current pressure ulcer on the coccyx. Resident 1' care plan included an air flow mattress, repositioning, etc. Facility staff failed to notify Hospice of the ulcer, failed to obtain treatment orders and failed to continue on going monitoring of the identified ulcer. Hospice assessed Resident 1 on 2/26/11 at 10:38 P.M., but did not complete a skin assessment at that time. Witnesses reported Resident 1's ulcer was likely a Kennedy ulcer and treatment would not have changed the progressions of the ulcer. All licensed staff received further in-service on policy/procedure for initial treatment and on going monitoring for residents at risk for pressure ulcers.",2,0,Substantiated,Substantiated,Neglect +BH146273,385221,NF,2/26/2014,"RV was admitted 2/26/2014 at 11:45 A.M. with diagnoses including behavioral disturbances. RV's medications were not delivered until 10:00 P.M. and RV did not receive the medication. Witnesses reported the pharmacy does not satellite medication from the pharmacy unless there was a ""critical"" need and staff reported they did not awaken RV to give the medication that night. While RV exhibited agitation and refused medication on 2/27/2014, W1 did not think the lack of medication on 2/26/2o14 was the issue. RV missed three doses of medication, was upset and is doing fine now per W2. the facility failed to ensure timely delivery of RV's medication. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST105991,385222,NF,12/18/2010,RV has a history of G-tube wounds with preventive measures in place. RV was receiving G-tube preventive wound care and sacral wound care when the sacral dressing wound care was discontinued. RP2 failed to properly transcribe the order and both the G-tube and sacral wound care was discontinued. RV's G-tube wound dressing change was not completed from 12/14 through 12/21/10. The G-tube wound did increase in size. RP2 received counseling for the transcription error and all staff received further in-service regarding proper G-tube dressing care. RP2 and all licensed staff should have been looking at the G-tube site and providing care. Per the investigation written 12/23/0 RV is doing well without signs of infection.,2,0,Substantiated,Substantiated,Neglect +ST116281,385222,NF,1/31/2011,"RP2 failed to change RV's bandage in a timely manner; RP2 asked RV if RV could wait until RP2 had finished the medication pass, but RP2 denied the bandage had soaked through at the time. RP2 did not get back to RV for 2 1/2 hours at which time the bandage had soaked through, but RP2 denies seeing bed linens soaked with drainage. RP2 failed to ensure RV's bandage was changed in a timely manner to keep RV's skin free of wound drainage. RV and RP2 give conflicting stories regarding how long RV laid in a wet dressing/linens. RV did not sustain notable skin injury, but RV did complain of being uncomfortable. RP2's employment was terminated. RV's treatment record was adjusted.",2,0,Not Substantiated,Substantiated, +ST116269,385222,NF,2/2/2011,RV2 was pulling on RV1's neck chain causing RV1 to choke. Staff heard the commotion and intervened. Staff were aware of RV1's outbursts and provided frequent monitoring. Staff were aware of RV2's agitation prior to RV1 and RV 2's interaction. RV1's care plan did not indicate one on one or more frequent monitoring of RV2's behavior when RV2 was agitated. All staff will receive additional information for dealing with dementia residents.,2,0,Not Substantiated,Substantiated, +ST116294,385222,NF,2/4/2011,"Witnesses indicated RV1 has a very short attention span for memory and has lashed out at other residents entering hi/her room. RV1 believes he/she has paid for the entire room and will vacillate between wanting a roommate and getting upset with other residents in the room. RV2 reported telling staff it would not work being moved into RV'1 room, but there was no other placement at the time. After the 2/4/11 event, RV1 had no further roommates. RV2 is unable to get out of bed without staff assistance and was upset over the event. The incident could have been prevented.",2,0,Not Substantiated,Substantiated, +OR0000690300,385222,NF,5/24/2011,"Resident 1 was admitted May 2011 with multiple diagnoses including a hip fracture and Alzheimer's. Resident 1 's assessment revealed short and long term memory loss and severe ""cognitive"" impairment. Resident 1 was identified as a fall risk with varied interventions care planned including being in a visible area when in a wheel chair and not being left alone in a room. Resident was to have alarms and not be left alone on the commode. On 5/21/11 Staff 1 (RP2) left Resident 1 alone on the toilet and returned to find Resident 1 on the floor. Resident 1 sustained a fractured left humerus. RP2 provided further information to include that RP2 left to respond to another resident, using oxygen, yelling for help. RP2 made a ""judgment call"" regarding the safety of either resident. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Not Substantiated,Substantiated,Neglect +ST128868,385222,NF,1/4/2012,RP2 failed to assist RV with toileting in a timely manner. RP2 failed to provide appropriate covering; left RV's room. Witnesses reported RP2 is a new CNA and requires help with time management. RP2 received further training and counseling. Staff spoke with RV. The facility failed to ensure RP2 was adequately supervised on a night shift when there is less staff resulting in less than stellar care for RV. Neglect of care was apportioned to the facility and constitutes abuse with violation of Oregon Administrative Rule.,2,0,Substantiated,Substantiated,Neglect +ST129743,385222,NF,4/4/2012,"Evidence does not support rough handling. RP2 failed to follow RV's care plan for decreasing RV's refusal of care and agitation. RP2 did not allow other staff to care for RV when RV's agitation increased. RP2 did report RV's behaviors, but failed to follow orders or the follow RV's request to stay out of RV's room. This failure to follow RV's care plan and honor RV's request represents a Oregon Administrative rule violation.",2,0,Not Substantiated,Substantiated, +ST129060,385222,NF,1/26/2012,"RV was admitted for rehabilitation on 1/7/12 and was non-ambulatory. RV's plan of care included intervention of re-positioning every two hours. Witnesses reported staff would check on RV, but not always turn/re-position RV. RV reported pulling his/herself up in bed using the head board; no other devices were available for use and that was how the decubitus ulcer occurred. RV actually developed shearing to the coccyx area and later developed non stageable ulcers. Witnesses reported there was a care conference on 1/3/2012, a trapeze was to be placed on RV's bed, but this did not occur for several days with W4 stating this was too late and the sores developed. The facility failed to consistently follow RV's care planned repositioning every two hours, failed to re-assess for a safer method to assist RV to move up in bed and failed to assess and or prevent developing decubitus ulcers. This failure constitutes neglect of care resulting in abuse and a Oregon Administrative Rule violation.",3,400,Substantiated,Substantiated,Neglect +ST121195,385222,NF,9/30/2012,"RP3 requested RP2's assistance in delivering a medication to RV. RP2 entered RV's room with another resident's medication and set the medication down on RV's table. RP2 failed to take the other resident's medication with him/her when RP2 left the room. RP3 saw the medication RP2 had left at the bedside, thought RV had failed to take the medication RP3 had given to RV at an earlier time and had RV take the medication left by RP2. RP2 failed to ensure the medications he/she had poured were secure and away from residents the medication were not intended for. RP3 failed to ensure the medication he/she gave RV were medication intended for RV resulting in a decrease in RV's blood pressure and unwarranted sedation. It was fortunate RP2 realized his/her error quickly and RV received immediate treatment and monitoring. The facility provided further in-service and training for staff.",2,0,Substantiated,Substantiated,Neglect +ST133276,385222,NF,5/21/2013,RV reported verbal interaction with RP2 including RP2 telling RV to get coffee themselves. Witnesses reported hearing yelling between RV and RP2; and RP2 telling RV to get own coffee. RP2 denies cussing at RV; only telling another staff person in RV's room what RV had said to RP2. Telling RV to get own coffee when RV is dependent for care would be inappropriate and honoring RV's choice in care. The facility did not fail to protect RV from emotional harm. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ST134272,385222,NF,8/27/2013,RV1 was readmitted on 8/27/2013 after hospitalization. RV was admitted with specific physician orders. The facility failed to follow the specific orders for over a period of time. RV denied any ill effects. Staff received further education An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ST134544,385222,NF,9/25/2013,"RP2 gave RV another resident medication. RP2 spoke with RV, but failed to check RV's wrist band prior to giving the medication. RV was at risk for harm per W1, but RV did not sustain negative effects. The resident MAR included the wrong room numbers. RP immediately reported the error and RV was monitored. An Oregon Administrative rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000852200,385222,NF,9/11/2013,A transcription resulted in a repeated medication error by multiple staff. The facility failed to have adequate systems in place to identify and stop the errors. The facility failure resulted in harm to the resident which constitutes abuse. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.,3,,Substantiated,Substantiated,Neglect +ST134744,385222,NF,10/15/2013,"The facility ran out of test strips. RV missed pre-lunch testing, but no evidence was found RV sustained known harm. RV1 reported the facility ran out of diapers and the resident was forced to wear the wrong size. Evidence was not presented to support the lack of diapers. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST135224,385222,NF,11/21/2013,"RV1 and RV2 were involved in an altercation. Witnesses reported RV1 had bit staff before, but not attempted to bite another resident. RV2 touched RV1's shoulder and RV1 reacted by biting RV2. RV1 has a history of traumatic brain injury. The majority of witnesses and RV1's care plan identify RV1's bite risk. RV1's care plan was updated for staff monitoring to ensure people are not entering RV1's personal space. Not all staff were adequately trained on working with RV1's biting behaviors. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST146168,385222,NF,1/23/2014,"RV and W5 reported RP2 failed to treat RV with respect when RV requested toileting assistance. The facility spoke with RP2 regarding ""gruff"" behavior. Witnesses reported RP2 had no prior complaints. RP2 received further counseling. RP2 left employment and gave conflicting reports of the circumstances. RP2 failed to treat RV with all due respect. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST146189,385222,NF,2/14/2014,"W3 reported night shift agency nurses put off things and number of resident had to wait over an hour for PRN med. W4 reported RVv asleep and med given later. W5 reported staffing was a major issue and there is a limit on how many staff per shift. W5 reported the majority of complaints are related to pain issues. W6 reported issues with call lights not always working. W3 reported call lights are usually answered within a few minutes, but emergencies can happen. Evidence is insufficient whether or not the call lights were a contributing factor to resident not receiving pain medication. Oregon Administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +ST146773,385222,NF,3/20/2014,"On or about March 20, 2014 at approximately 1:00 P.M. RP2 approached RV to provide care. RV reported never seeing RP2 before, RP2 was ""horrible"", RV told RP2 to stop and RP2 hurt me. RP2 continued to provide care despite RV's resistance to care and RV saying ""no""; RP2 failed to honor RV's choice in care; and failed to seek staff assistance and or guidance when RV resisted care. RV sustained injury to gentalia skin. RP2 was agency staff and had never cared for RV before. RP2 was not the assigned aide for RV and did not know about RV's behaviors before starting care. The facility failed to adequately instruct and or supervise RP2's care of RV. The facility failure constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Physical Abuse +ST146848,385222,NF,3/26/2014,"RV sustained a delay in use of a toileting device with RV describing ""sweats"" and discomfort. The actual time frames from RV's initial call light and assistance provided are questionable, but RV did sustain some discomfort. RV's request for assistance was delayed. The facility has taken reasonable precautions to prevent a similar future event. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST146762,385222,NF,3/19/2014,"RV1 reported care is great and it was a one time event when waiting for call light response. RV1 reported staff were very busy that night. RV2 reported getting diarrhea and it was embarrassing, but staff apologized. RV2 reported staying at the facility several times and this was the only problem. Staffing met the minimal requirements on this night. RV2's delay in toileting may have felt urgent. Staff deny the probability of an hour delay; maybe up to 30 minutes. W4 reported seeing some call lights dysfunctional. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000881400,385222,NF,3/6/2014,Resident 1 was admitted 2009 with multiple diagnoses. Resident used a urinary catheter and had a history of UTIs. Resident 6 was admitted 2012 with multiple diagnoses and used a catheter. Staff failed to use a catheter on residents 1 and 6 with ordered balloon size and failed to notify resident physician of this action. No evidence was found to indicate actual harm to the residents. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +ST146916,385222,NF,4/27/2014,"RV reported receiving $28.00 (specific sum) on 4/26/3014money went missing 4/27/2014, RV denied observing any resident in his/her room and denied nay family would have taken the money. RV was not provided a locking drawer/key upon move in. The facility failed to provide a safe environment resulting in theft of RV's money. The facility investigated, reported the theft, reimbursed RV and provided a locking drawer. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Financial abuse +OR0000886002,385222,NF,3/26/2014,Resident 1 was re-admitted 3/1/2014 with multiple diagnoses including new and primary diagnosis of grand mall seizures. Resident physician orders included Dialantin and record review found 15 refusals of medication between 3/1/2014 and 3/31/2014. Review found no evidence the physician or family were notified or other measures were attempted. The resident was re-admitted to the hospital from dialysis. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Rule violations occurred.,2,,Inconclusive,Substantiated, +OR0000886006,385222,NF,3/26/2014,"Resident 1 was re-admitted in 2013 with multiple diagnoses. The resident's 3/11/2014 Fall Injury Assessment and care plan identified fall risk and interervention including anti-tip bars on the wheel chair. On 4/14/2014 the resident was found on the floor; wheel chair tipped backwards, skin tear to the right arm and resident complaining the back of his/her head hurt. A 4/17/2014 building service work order identified anti-tip bars do not lock in place. On 5/22/2014 the bars were observed to be taped in place, but not locking. The resident was at risk for harm. Relevant portions of the surveyare attached. Enforcement action was recommended. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000895000,385222,NF,5/7/2014,A complainant health survey conducted 05/20/2014 through 06/16/2014 found the facility failed to ensure sufficient staff to meet the minimum CN.N.A. to resident ration. On 5/16/20124 resident census was 50 which required 6 CNAs for evening shift. There were 4 CNAs and one NA. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ST147337,385222,NF,6/8/2014,"RP2 reported to the investigator that RP2 was nervous, may have been having a vertigo episode, had taken pain medication prior to going to work, may had trouble walking and may have been in a hurry while working. W3 reported ""numerous"" resident complaints regarding RP2 the day RP2 worked. W4 reported seeing RP2 throw up in the hallway, observed RP2 moving in an unnatural way and being ""scared"" by RP2. RV reported RP2 argued with RV over who RV was when RV attempted to tell RP2 the medication RP2 was trying to give RV was not RV's medication. RV also reported RP2 stuck RV with a needle and that RV was very scared of RP2. W2 observed RP2 attempt to give a combination of other resident medications to RV and RP2 was asked to leave RV alone. Preponderance of evidence supports RP2 arguing with RV, scaring residents by RP2's behavior and working while knowing RP2 was impaired ( vertigo, nervousness, confused, etc.). RP2's actions constitute abuse by neglect. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Neglect +ST147338,385222,NF,6/6/2014,"RV reported RP2 continued to take RV's blood pressure despite RV saying no and it hurts. RV did not sustain visible injury, but reported arm hurting after the procedure. RP2 reported RV's care plan did not contain instruction specific to blood pressure, i.e.. Not to take blood pressure on the arm in question. RP2 reported RV complained just as RP2 finished the procedure and was taking cuff off. RP2 was orienting to resident care and RP2's co worker who was to take the blood pressures had been gone an hour so RP2 took the blood pressures. RP2 reported most of his/her experience was with monitors for blood pressure. RP2 was told not to provide care to RV, but did enter RV's room later as RP2 just did not think about the instruction. Additionally RP2 failed to tell the charge nurse of the events. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ST147916,385222,NF,7/24/2014,"The facility failed to adequately plan for RV's care needs resulting in RV's continued discomfort and loss of dignity constituing neglect and abuse. RV left for an early A.M. physician appointment without adequate hygiene or grooming, no breakfast or pain medication given. Many witnesses reported the facility knew RV had an early appointment. RV did receive pain medication and bathing on return. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ST148716,385222,NF,8/11/2014,"RP2 failed to provide incontinence care for RV1, RV2, and RV3 per RV's care plan and or facility guidelines. Specifically RP2 provided last rounds to care for RV2 beginning at 3:00 A.M. instead of 4;00 A.M. as witnesses spoke to regarding facility care planning for resident care. Given shift changes RVs may not receive further care until 7:00 or 8:00 A.M.; and therefore could become quite soaked with urine. RV1, RV2, and RV3 did not sustain noted skin issues as one would expect if they had been left in urine for an extended period of time. None of the RVs voiced much concern regarding their care, except RV3 reported staff on night shift were rather scarce. Oregon Administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +ST148875,385222,NF,8/4/2014,"RV has limited ability for interview; using thumb gestures. Documentation and interview evidenced indicates RV went approximately 14 hours without nutrition, fluids and medication when RP2 failed to find RV's physician orders on RV's return at 6:00 P.M. on 8/4/2014. RV's feeding, medication and fluids began at approximately 7:45 A.M. on 8/5/2014. RV was able to convey hunger per W5, but there was no evidence of this the evening of 8/4/2014. While there was no evidence of harm, the risk existed. RP2 readily admitted fault in this issue and received counseling. Review found RV's medical record and documentation was incomplete. Oregon Administrative Rule violations occurred.",2,,Inconclusive,Substantiated, +ST148361,385222,NF,9/1/2014,"Complainant 1 and 2 voiced multiple concerns as described in the attached report. RV reported staff bumped RV's lower extremity during transfer causing pain, but does not feel it was intentional. RV reported a delay in receiving medication and being awakened during the night contrary to request not to be awakened. Witnesses are aware of the concerns and confirm certain aspects of the concerns, i.e.. Breaking medication (physician orders okayed this), accidently bumping RV's lower extremity, requesting not to be awakened and a delay in giving pain medication when RV refused later than usual. Evidence supports RV's wish not be awakened has not always been honored as staff are required to check on RV at night. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST148411A,385222,NF,9/5/2014,"The facility failed to ensure RV's call light was in place so RV could alert staff to RV's need for commode use. RV did not receive timely service resulting in RV using a pillow case to urinate in. RV reported being up set, angry and in tears as the result of slow staff response and having to use a pillow case to urinate in. The facility failure resulted in neglect of care and a significant loss of dignity which constitutes abuse. Oregon Administrative Rule violations occurred.",3,300,Substantiated,Substantiated,Neglect +ST149281,385222,NF,11/14/2014,"The complainant reported RV's hand was ""forcibly"" removed from the hand rail; RV was forcibly removed from the hallway. RV was unable to give reliable information. RP2 reported RV was running his/her wheel chair into other residents, RV resisted redirection, and RV planted his/her feet on the ground. W1 reported RP2 pried RV's hand from the rail and RP2 was talking ""rough"" to RV. W1 reported RV was yelling and cussing at RP2. W3 reported RP2 was a ""little"" impatient and failed to give RV enough time to comply with redirection, but denied RP2 ""yelled"" RV. W4 denied observing RP2 intend any malice toward RV. W5 reported no marks on RV and RP2 used the skills they had to work with RP2 failed to treat RV with all due respect while redirecting RV. RP2 failed to give RV enough time to assimilate and comply with redirection. RV's care plan was adjusted for staff to better deal with RV An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST149384,385222,NF,11/24/2014,"RV reported through spouse that staff failed to adequately clean RV over the weekend (identified as 11/22 & 11/23/2014), RV was left in dirty undergarments, staff did not enter RV's room on night shift often enough and RV has groin pain from not being changed often enough. W1 reported seeing RV three times each on Saturday and Sunday (11/22 & 11/23/2014); found RV incontinent and in dirty clothing two of each three times. W1 reported RV's groin is raw from RV laying in dirty garments for too long a time. Multiple witnesses reported RV is unable to communicate effectively except to answer yes/no questions; and RV's care plan indicates incontinence and repositioning care. W5, 6 and 7 report the facility was short staffed on Saturday and Sunday (11/22 & 11/23/2014). The facility failed to provide adequate staffing and incontinence care to meet RV's needs resulting in RV's skin changes and pain. RV's neglect of care constitutes abuse. Oregon Administrative Rule violations occurred.",3,500,Substantiated,Substantiated,Neglect +ST149346,385222,NF,11/21/2014,RV2 had asked staff multiple times to have RV1 turn down the TV volume. RV1 and RV2's frustrations resulted in a verbal altercation. RV1 and RV2 threatened each other. RV2 was moved to another room. The facility failed to assess and care plan for RV's needs resulting in RV1 and RV2's verbal altercation and threats. Both RV s were at risk for harm. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +ST149441,385222,NF,11/25/2014,"On or about November 21, 2014 at approximately 5:50 A.M. RV requested pain medication and did not receive the medication until 7:20 A.M. RV may receive PRN pain medication every four hours as needed; RV's last dose of PRN pain medication was given at approximately 9:35 P.M. on November 20, 2014. RV reported staff are wonderful, but has waited more than once for their pain medication. RV reported the longer RV has to wait for pain medication the more their emotional feelings kick in; there is no physical damage, but just ""agony"". Neither, RV or other resident should have to wait over one and one half hours for requested pain medication if the dosage is within the time frames to be given. RV's increased emotional distress and physical pain constitutes neglect of care (abuse). Oregon Administrative Rule violations occurred.",3,250,Substantiated,Substantiated,Neglect +OR0000941000,385222,NF,12/18/2014,"Resident 3 was admitted 10/01/2014 with multiple diagnoses including an open left ankle fracture, an open right foot fracture and acute post operative pain. The facility had specific protocol for post operative care. On 11/03/2014 physical therapy identified left ankle swelling, but no documentati0n of visual assessment for infection. On 11/05/2014 the physician progress note identified the lateral left ankle incision had "" pinpoint sinus that has been draining over 1 to 5 weeks"" and the physician noted concern regarding an underlying infection. The resident had complained of left ankle pain a week prior to 11/05/2014, nurses never pulled back the covers or looked at the surgical site for infection. The facility failed to complete on going wound assessment placing the resident for further risk of undetected wound infection. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ST150376,385222,NF,2/25/2015,"RV was not provided timely pain medication as RV requested and within the time parameters as RV_x001A_s physician ordered. RV requested pain medication at approximately 9:00 A. M. and again a second time around 10:00 A.M. as noted in the Resident Concern Form, RV statement and witness statement. RV did not receive the requested pain medication until approximately 10:50 A.M. resulting in RV_x001A_s unnecessary continued pain and suffering. The facility failure to promptly provide RV with the requested pain medication constitutes neglect and abuse. Oregon Administrative Rule violatons occurred.",3,200,Substantiated,Substantiated,Neglect +ST150437,385222,NF,2/27/2015,"RV reported keeping his/her wallet in an unlocked night stand, RV checks the wallet and money every morning, RV was moved and RV's money went missing. RV denies using the money at the facility and should have had between $30.00 and $50.00. witnesses report RV claimed RV's roommate took out RV's money and threw away the wallet, but no cash was found. Witnesses report RV's roommate is visually impaired and unable to open the wallet to tell what was inside. RV did not report RV's roommate to the investigator. Evidence is inconclusive how RV's money went missing. The facility will replace the money. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +ST150636,385222,NF,3/20/2015,"RV reported staff treat them great, has difficulty keeping oxygen levels up and has pulled oxygen delivery device out of their nose during sleep. RV related he/she received a tube feeding through a tube down their nostril causing a problem with oxygen delivery and staff tried masks, but RV wanted the other device. The complainant reported staff failure to give RV his/her oxygen breathing tube caused lowered oxygen saturation to the point of 74%. RP2 reported RV received oxygen per facility protocol, but evidence presented confirmed RV's oxygen levels fluctuated. Staff obtained other tubing, but RV was left without oxygen for approximately 10 minutes. RV's oxygen level slipped a little further, but then came back up. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST150739,385222,NF,3/29/2015,"The complainant voiced concerns regarding RV not receiving scheduled narcotic medication on 3/28/2015 and 3/30/2015, as well as, not receiving other scheduled medication on 3/27/2015 and 3/29/2015. RV was unable to give relevant information. Witness interview and documentation review revealed RV did not receive scheduled narcotic pain medication due to required need for physician signature and or a delay in obtaining the signature. RV did not receive scheduled medication for memory. Failure to receive the scheduled memory medication effects RV's stability and judgment. W5 reported RV sustained two non-injury falls during the time RV did not receive the scheduled memory medication. Failure to provide scheduled medication placed RV at significant risk for harm. The facility failure to ensure a safe medication system resulted in neglect of RV's care which constitutes abuse. Oregon Administrative Rule violations occurred.",2,250,Substantiated,Substantiated,Neglect +ST150750,385222,NF,3/31/2015,The complainant reported RV did not receive a scheduled prescription as physician ordered. RV reported forgetting to ask for the applied medication and staff did not bring the medication. RV reported being treated great and had no problem with the medication being stopped. RV received medication a few times and the skin condition cleared. The physician order was some what ambiguous per witness statements. Technically RV did not receive the medication as ordered. RV did not sustain negative effects. Oregon Administrative Rule violation occurred.,0,,Not Substantiated,Substantiated, +ST150779,385222,NF,4/1/2015,"RV received oral surgery known to cause significant discomfort and pain. RV's physician ordered a scheduled narcotic pain medication following RV's surgery. The narcotic medication order was improperly transcribed to RV's MAR as a PRN. The facility failed to have an adequate system in place to ensure the physician ordered medication was properly transcribed to RV's MAR. Witnesses report RV does not push the call light to request pain medication and RV is known to say no to staff inquiry due to RV's cognitive issues. W3 stated staff must explain to RV when RV is in pain and that RV can ask for pain medication, but RV forgets. RV indicated to W4 that RV's mouth was painful, but RV did not receive pain medication for hours after the surgery. The facility failure to ensure an adequate medication delivery system resulted in RV's continued pain and discomfort. The facility failure in providing care and services for RV constitutes neglect of care and abuse. Oregon Administrative Rule violations occurred.",3,450,Substantiated,Substantiated,Neglect +ST150187,385222,NF,2/3/2015,"Staff interview, as well as, RV1 and RV2 interview identified facility failure to provide timely care. Staff assigned to provide care to RV1 and RV2 were also assigned to provide care for residents on another hallway. Multiple staff report it is easy to forget to check on residents when assignments are split between hall ways. Multiple staff report staffing issues impacting resident care. Facility failure to provide adequate care and services resulted in RV1 and RV2 not receiving timely toileting and or incontinence care. The neglect of RV1 and RV2's care for over five hours resulted in resident discomfort constituting abuse. Oregon Administrative Rule violations occurred.",2,250,Substantiated,Substantiated,Neglect +CO15130,385222,NF,6/25/2015,In review of the FMG Northeast Weidler Street Oregon LLC licensee application it was found that one applicant failed to meet all criteria required to meet approval as a new licensee. Specifically the applicant failed to have a record of good credit as evidenced by an OLRO credit check.,2,0,Not Substantiated,Substantiated, +ST151063,385222,NF,4/25/2015,"Witness interview, documentation review and RV's interview revealed RV requested pain medication at approximately 8:30 A.M. on April 25, 2015 for his/her headache, but RV did not receive the medication until after 1:30 P.M. W2 reported staff spoke with RV after RV reported having a headache along with upper arm pain and RV stated not needing medication just some quiet time. RV stated telling staff 2 or 3 times on April 25, 2015 that RV had a headache and RV did not receive the pain medication until after 2:00 P.M. RV reported having a lot of pain on April 25, 2015. RV reported receiving medication in yogurt on April 25, 2015 despite RV telling staff they cannot have dairy products as it causes incontinence. RV has a history of incontinence with or without dairy, but the dairy products make the incontinence worse. RV and the April 29, 2015 incident report indicate RV had increased incontinence after being given medication in yogurt on April 25, 2015. The facility failure to provide adequate care and services resulting in RV sustaining continued pain and suffering for several hours constitutes abuse. Oregon Administrative Rule violations occurred.",3,300,Substantiated,Substantiated,Neglect +ST151062,385222,NF,4/24/2015,"On April 23, 2015 between 10:00 A.M. and 10:30 A.M. RV sustained a second degree burn to RV's right lower extremity (foot) due to use of a warming device. RP2 placed the device at 10:00 A.M. and asked RP3 to remove the device in ten minutes. RP3 became distracted and the device was left for an additional twenty minutes resulting in the device being left in place approximately thirty minutes. RV reported attempts to remove the device after ten minutes and attempts to summon help to remove the device, but was unsuccessful. RV reported suffering pain and emotional distress due to the incident. The facility failed to have an adequate policy/procedure in place regarding the use of the device which contributed to RV's injury. The facility failure to provide adequate care and services constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +ST151199,385222,NF,5/3/2015,"RV pushed the call light ands staff were so slow RV self transferred to the toilet. One time RV sustained severe pain attempting to clean self after toileting. RV ""felt"" humiliated by staff actions and service by staff resulting in RV's pain. Neglect of care constitutes abuse. Oregon Administrative Rule violations.",2,,Substantiated,Substantiated,Neglect +ST150713,385222,NF,3/26/2015,"RV reported staff delay in answering RV's call light and delays in providing pain medication. RV reported waiting over an hour for pain medication, was in severe pain and close to crying. RV reported call light response is better today (3/26/2015). Facility failure to provide RV with adequate care and services resulting in RV's delayed pain relief constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ST151214,385222,NF,5/9/2015,RV reported being upset on 5/9/15 having to wait for A.M. medication until 11:45 A.M. or 12:00. RV reported suffering extreme pain. RV reported they were certain they requested the medication at least once. RV voiced concern regarding RV's oxygen level and RP2 telling RV to take deep breaths. RP2 reported a facility emergency that took RP2 away from administering A. M. medications and reported knowing RV liked A.M. medication at 8:00 A.M. RP2 reported not reading facility policy regarding medication administration. Witnesses and RP2 gave conflicting statements in knowledge of when A.M. medication was to be delivered. The facility failed to ensure RV's A.M. medication was delivered timely resulting in RV's increased and or prolonged pain. The failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +ST151248,385222,NF,5/12/2015,RV reported not receiving A.M. medication and or not receiving medication timely. RV reported just recently learned that cut off for A.M. medication is 10:00 A.M. RV denied suffering any increased pain or illness. RP2 observed RV coming in well after 12:00 P.M. on 5/10/2015; sometime between 12:30 and 1:00 P.M. RP2 did not refuse to give RV PRN medication. RP2 reported RV was upset during the P.M. medication pass. On 5/9/2015 there was a delay in delivering A.M. medication due to another resident emergency. RP2 reported never seeing or reading a facility policy regarding medication administration times. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +ST151731,385222,NF,6/25/2015,"RP2 took over passing medication at 8:30 A.M. on 6/25/2015; RV requested medication at 10:00 A.M. and RP2 misread the narcotic medication count sheet and told RV that RV had received medication at 7:30 A.M. RP2 recognized the error, gave RV medication at 10:20 A.M. and apologized to RV. W2 reported staff covering the hallway prior to RP2 were told RV was requesting pain medication at around 7:00 A.M. The facility failed to ensure that an adequate medication system was in place resulting in confusion and RV's delay in receiving pain medication timely. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ST152922,385222,NF,9/24/2015,"The facility failed to ensure all staff received appropriate information in order to provide care. RV arrived at approximately 2:30 P.M. on 9/24/2015, but staff were aware of RV's wound vac and device for defecating. RV's medications were unavailable and the pharmacy was called. RP2 misread the physician orders, did believe the orders were ""strange"" to ' hook up the wound on 9/25/2015 and failed to clarify the order. RV's wound was cleaned and the wound vac attached on 9/25/2015. RV did not sustain known negative outcome. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ST153161,385222,NF,10/13/2015,"RV stated being abused, reported RP2 was short tempered and RV needed to hurry as RP2 had 15 patients. RV reported hitting RV's right ankle on the wheel chair foot leaver; RP2 was in a hurry and pulled RV's catheter. RP2's statement regarding interaction with RV was different, but RP2 sated RP2 is fast and RV may have felt rushed. RP2 sated the catheter line could have become taunt for a moment while assisting RV with clothing. RP2 does not recall bumping RV's foot or ankle on anything. Preponderance of evidence finds RP2 was rushing and should have slowed down. Evidence does not support RP2 deliberately pulling on RV's catheter line. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated,Neglect +ST153098,385222,NF,10/7/2015,The complainant reported facility failure to provide RV's pain medication A for 36 hours and pain medication B for 13 hours. W1 reported RV's family member saw RV and it was obvious RV was in pain. Interview and record review indicate RV went 24 hours without pain medication A but received medication B. RV's medication A was not copied onto the October MAR. RV received Medication B as it was documented on the September MAR. The facility failed to provide an adequate medication system as RV did not receive all medication as ordered and RV sustained avoidable pain. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +ST164590,385222,NF,2/11/2016,"RV reported RP2 is nice to them. RV reported one time event of RP2 saying ""RV had to eat their food before they could have any other liquids. RP2 does not recall an event as described. RP2 reported not knowing RV's routine; may have asked RV to come out to the door way so staff could observe RV; RV is an aspiration risk. Witnesses report RV often refuses dinner and ""RP2 tricked RV into eating"". RV's choice to consume fluids without eating was not honored on more than one occasion. Oregon Administrative Rule violation occurred..",2,,Not Substantiated,Substantiated, +ST164682,385222,NF,2/18/2016,The facility failed to care plan and provide intervention for providing proper nail care for RV. RV requires specialized nail care due to RV's medical condition. There was no record of RV's nail care. RV's toe nails were very long and growing into RV's skin; finger nails were reportedly in similar condition. RV's lack of nail care resulting in nail growth into RV' skin was preventable. RV received nail care only after family reported their concerns. Oregon Administrative rule violations occurred.,2,,Substantiated,Substantiated,Neglect +MV116545,385224,NF,2/5/2011,Evidence and interviews indicated facility failed to adequately plan Resident #1's discharge.,2,0,Not Substantiated,Substantiated, +OR0000688800,385224,NF,5/16/2011,"Evidence and interview indicated facility failure to provide adequate pain control care and services for Resident #1. Relevant portions of the survey report are attached, federal penalty recommended.",3,0,Substantiated,Substantiated,Neglect +MV118175,385224,NF,10/4/2011,"Evidence and interviews indicated RP2 (CNA) physically restrained and or failed to follow RV's care plan forcing RV to finish showering against her/his will on 10/4/2011 which resulted in RV sustaining unreasonable discomfort. W2 observed bruises to RV's arms, but was unable to determine how old or new the bruising was. Further evidence finds RP3 failed to fully understand RV's care plan as RP3 was not a primary care giver for RV on the event date and was assisting to only transfer RV. The facility failed to ensure all staff properly understood bathing care for RV resulting in neglect of care which constitutes abuse of RV.",3,0,Substantiated,Substantiated,Neglect +MV118032,385224,NF,9/12/2011,"Evidence and interviews indicated facility failure to adequately administer Resident #1's medication resulting in Resident #1 receiving incorrect medications and feeling dizzy, weak and confused.",3,400,Substantiated,Substantiated,Neglect +MV132694B,385224,NF,3/19/2013,Evidence and interviews indicated facility failure to ensure adequate toileting assistance for Resident #1 resulting in Resident #1 sustaining pain. Facility failure to ensure Resident #1 adequate toileting assistance are considered neglect of care and constitutes abuse.,2,0,Substantiated,Substantiated,Neglect +OR0000819700,385224,NF,3/21/2013,"Evidence and interviews indicated facility failure to ensure a safe environment for Resident #1. Facility staff had knowledge Resident #1's bed was faulty, however the bed was not repaired when Resident #1 reported slipping during a self-transfer on 03/16/2013 when the bed moved. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0000845701,385224,NF,8/13/2013,"Evidence and interviews indicated facility failure to ensure facility staff documented, assessed and documented a late entry in a timely manner and changed documentation without proper documentation for Resident #1. Resident #1 fell, sustained a subdural hematoma and died in the local hospital secondary to head injuries. + + + +The facility failure to ensure Resident #1 received the necessary care and services after falling and sustaining a subdural hematoma and dying in the local hospital secondary to head injuries are violations of resident rights, are considered neglect of care, and constitutes abuse. + + + +Federal penalties recommended, relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +MV135277,385224,NF,12/3/2013,"Evidence and interviews indicated Resident #1 was ordered to receive oxygen however the water in the oxygen concentrator ran out for more than 24 hours. The facility failure to ensure Resident #1 received the necessary care and services regarding oxygen treatment resulting in Resident #1 sustaining unreasonable discomfort and a sore inside her/his nose are violations of resident rights, are considered neglect of care, and constitutes abuse.",2,250,Substantiated,Substantiated,Neglect +MV151597,385224,NF,6/10/2015,"Evidence and interviews were inconclusive related to an allegation of failing to protect Resident #1 from rough treatment by facility staff related to upper extremity bruises. However, evidence and interviews indicated facility failure to adequately document Resident #1's upper extremity bruising first documented 6/13/2015.",2,,Not Substantiated,Substantiated, +OR0000975800,385224,NF,6/15/2015,Evidence and interviews indicated facility failure to ensure minimum staffing requirements for nursing assistant to resident ratio was provided for (1) of (15) evening shifts reviewed and (1) of (15) night shifts reviewed. Facility failure to ensure adequate staffing requirements placed residents at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000975801,385224,NF,6/15/2015,"Evidence and interviews indicated facility failure to ensure Resident #2's assistive device (mattress on the floor) were in place when Resident #2 had an unwitnessed fall on 6/13/2015. Facility information indicated Resident #2_x001A_s unwitnessed fall on 6/13/2015 was a non-jury fall. However, facility failure to ensure interventions placed Resident #2 at increased risk for fall injury. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001053000,385224,NF,1/20/2016,"Evidence and interviews indicated facility failure to provide adequate care and services regarding Resident #2's bathtub related to a brown rusty ring around the inside of the bathtub observed on or about 3/8/2016. Surveyor observations of the bathtub on or about 3/10/2016 after housekeeping staff scrubbed the bathtub ring, indicated the ring was greatly faded.",2,,Not Substantiated,Substantiated, +OR0001053001,385224,NF,1/20/2016,"Evidence and interviews indicated facility failure to ensure an allegation related to Resident #2 sustaining a fall was investigated. This failure placed Resident #2 at risk for potentially unaddressed abuse and neglect. In addition, evidence and interviews indicated facility failure to ensure Resident #2 was transferred with the assistance of two staff as care planned and reflected in Resident #2_x001A_s care plan dated 11/14/2015. This failure placed Resident #2 at risk for avoidable injuries; relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001053003,385224,NF,1/20/2016,"Evidence and interviews indicated facility failure to provide adequate staff to meet resident care needs. A review of staff payroll records and documentation indicated eight certified nursing assistant staff coverage shortages from 11/8/2015 through 2/21/2016. In addition, there were five occasions in February 2016 when 40% of evening shift staff consisted of uncertified nursing assistant (NA_x001A_s) and two occasions where 33% of night shift staff consisted of NA_x001A_s. The resulting CNA shortages violated minimum CNA staffing standards; relevant portions of the complaint report investigation are attached.",3,400,Not Substantiated,Substantiated, +OR0001055700,385224,NF,1/26/2016,Evidence and interviews indicated facility failure to adequately update and revise Resident #3's care plan for fall interventions. Facility failure to maintain an adequate care plan for Resident #3 placed Resident #3 at risk for injury; relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001055701,385224,NF,1/26/2016,"Evidence and interviews indicated facility failure to consistently monitor Resident #3's meal intake and provide supplements to prevent Resident #3 from losing weight. The facility failure to ensure Resident #3 was provide adequate nutritional care and services resulting in Resident #3's unplanned weight loss are considered violations of resident rights, are considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +OR0001062801,385224,NF,2/12/2016,Evidence and interviews indicated Resident #5 admitted to the facility in December 2015 with multiple diagnoses including multiple stasis ulcers on both legs and heel pressure ulcers. December 2015 hospital discharge instructions included wound care with Unna Boots (leg wraps) twice a week. Evidence and interviews indicated multiple instances without documentation Resident #5's wound care treatment was provided as ordered placing Resident #5 at risk for unmet needs. Civil Penalty NFCP16-057 was assessed for facility failure regarding Resident #5; relevant portions of complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0001062802,385224,NF,2/12/2016,"Evidence and interviews indicated facility failure to ensure adequate monitoring and treatment for a newly developed pressure ulcer identified on Resident #5_x001A_s right, upper buttock on or about 1/16/2016 placing Resident #5 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001064800,385224,NF,2/18/2016,"Evidence and interviews indicated facility failure to provide Resident #5 and Resident #6 adequate wound care and treatment services. Evidence and interviews indicated multiple instances without documentation Resident #5_x001A_s wound care treatment was provided as ordered placing Resident #5 at risk for unmet needs. In addition, The facility failure to ensure Resident #6 received the necessary care and services regarding wound care and treatment services resulting in Resident #6 sustaining continued skin issues are violations of resident rights, are considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,600,Substantiated,Substantiated,Neglect +OR0001065300,385224,NF,2/19/2016,Evidence and interviews indicated facility failure to provide Resident #7 sufficient oxygen during transport to a physician appointment. This failure placed Resident #7 at risk for unmet needs; relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000682800,385225,NF,4/13/2011,"Resident 1 was admitted 2/11/1 with multiple diagnoses and assessed risk for decubtus ulcers. On 2/18/11 Resident 1's old knee immobilizer was replaced by physical therapy without assessment for fit, positioning or physician order for use. A ""scrape"" was discovered to Resident 1's left ankle on 3/6/11; appears the brace rubbed the ankle. No assessment of the wound occurred between 3/6/11 and 3/15/11 when the length and width had changed. No further assessment was found until 3/24/11. By 3/31/11 the wound was assessed as a Stage III. Resident 1 visited a wound clinic on 3/24/11 with orders for a new immobilizer, but there is no documentation the order was followed. Staff failed to document assessment of the brace related to risk of pressure ulcers, prior to occurrence or after their occurrence. Relevant portions of the survey area attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000727000,385225,NF,11/9/2011,"Resident 1 was admitted 8/13/2011 with diagnoses including a fractured ankle. Resident 1's pain admission screening and comprehensive assessment date 8/13/2011 indicated left ankle pain with intensity of ""7"" effecting resident sleep and ability to participate in therapy. Staff failed to consistently rate the intensity of Resident 1's pain and pain medication changes were without evidence of an updated pain assessment. Resident 1's follow-up two week appointment with the orthopedic surgeon was not kept. Resident 1's staples were not removed until 10/18/2011. Resident 1 was at risk for harm. Relevant portions of the survey are attached. Enforcement action was recommended.",2,0,Not Substantiated,Substantiated, +OR0000739600,385225,NF,1/12/2012,"Resident 1 received transdermal Duragesic patch for pain; to be changed every 72 hours. Initials of the MARs indicated the patch was changed on 1/3, 6 & 9/2012, the patch placement was initialed as being checked at the beginning of each shift. Staff 2, 3 and 4 felt for the patch and signed as it was in place without looking at the patch and the initials. Staff failed to rotate the patch as procedure directed. Staff failed to assess resident's increased complaint of pain and the increased use of PRN pain medication. Resident 1 sustained uncontrolled pain due to not receiving the ordered Duragesic patch. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +MM118516B,385225,NF,11/2/2011,"The complainant reported RV's Fentanyl patch went missing and 6 patches have been missing in last 3 months. Resident Fentanyl patches are being checked frequently. Staff have tested negative for the narcotic. RV2 failed to respond to the investigator, RV 3 reported he/she did not think the patch did any good. While RV 4 was missing a patch on 11/11/2011, evidence was not conclusive RV 4 experienced an increase in pain on this particular date. The facility failed to ensure an adequate medication system was in place. This system failure resulted in missing medication patches and resulted in a Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Financial abuse +MM129841,385225,NF,1/23/2012,"A prior similar event occurred 6 month ago in which RV ""slid or fell"" out of the Hoyer sling. RV reported at the time of this event the sling was hooked up right and he/she ""slid"" out of the sling. W2 (staff) reported ""a hard time finding another staff"" to help with the Hoyer transfers. Although W1 reported we have enough staff, RP2 and RP3 reported staffing as a issue in obtaining the help of a second person. During the recent incident RP2 reported the facility being short of help, so attempted transfer by him/herself, RV slid down and was hurt. RV was transferred for treatment and returned in few days with ""some pain"". RP3 mentioned during the prior event RV's sling slid, did not support RV and RV slid to the floor. The previous event was not reported because RP3 ""caught RV"" and RV did not ""fall"". RP3 reported ""for years"" it was ok to transfer using the Hoyer and ""did not realize it was not ok"". W2, RP2 and RP3 reported they now use only two people for transfer; wait for help. The facility failed to adequately train, adequately supervise; and or staff the facility to ensure RV was transferred appropriately resulting in RV going to the floor and sustaining a hip fracture, along with various bruises. The facility failure constitutes abuse and violation of Oregon Administrative Rule.",3,400,Substantiated,Substantiated,Neglect +MM129980,385225,NF,5/1/2012,RV received pain medication PRN TID between 5/1 and 5/4/2012. RV did not receive topical pain medication (Lidocaine) nor was it written on RV's MAR as of 5/4/2012. RV did say he/she was not in too much pain when interviewed 5/4/2012. the facility failed to ensure a safe medication system was in place. RV did not receive medication as ordered and available to the facility. This facility failure represents a Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +MM129952,385225,NF,4/25/2012,"RV and witnesses reported RP2 can be rude, bossy and told residents not to use their call lights. RV reported at the time of the incident RP2 came into his/her room and told RV to shut up and go to bed, as well as, not use the call light anymore. RV reported being fearful of RP2 and was afraid to push the call light , thought RP2 might come back and ""slug"" RV. RP2 reported RV had used the call light 25 times and was getting frustrated, but denied telling RV not to use the call light. Witnesses and RP2 reported prior counseling for similar behavior. The facility has counseled RP2 in the past, suspended and terminated RP2's employment.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MM129308,385225,NF,2/8/2012,"On the evening of 2/8/2012 RV reported RP2 yelled at RV and said RP2 didn't care about RV's ""God dam genitals"". RP2 denies yelling or swearing at RV. Witnesses reported hearing RP2 yell at RV and reported when entering RV's room shortly thereafter RV reported the yelling, the swearing and monstrous tone of voice used by RP2. W7 reported RV appeared fearful when W7 went in to speak to RV. RP2 failed to treat RV with respect and dignity. Facility staff failed to immediately report the incident (W1 received the complaint on Monday; February 13, 2012) placing other residents and RV at risk for similar interaction with RP2 on shift of 2/9 to 2/10/12. The facility failed to provide a safe environment and failed to immediately report suspected abuse. This failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MM121616,385225,NF,10/19/2012,"RP2 worked night shift and did not apply a medication patch prior to RV's outing. RV became nauseated and not able to go out. The facility day shift begins at 6 A.M. and would have normally given the medication, but due to a call in night shift was attempting to assist with medication beginning at 5 A.M. and medication was missed. Additionally social services will be putting physician visits on a calendar and put medication 4 hours prior to the visit. The facility failure represents and Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Neglect +MM132321,385225,NF,2/2/2013,"The complainant reported lack of bathing/clothes changing for RV on multiple days from January 27, 2013 through February 2, 2013. RV reported wishing he/she could get showers more often and staff leave it up to RV to change his/her clothes. W2 confirmed less laundry and when asking staff the staff reported ""we'll get to it"". ""We do not have a DNS."" W2 voiced concern regarding abscesses on RV's bottom and the need to have clothing changed. W3 reported staff stating RV does not want a shower; RV has dementia and they have to ""cajole"" RV. W4 stated when asking about RV's weight staff said RV is a failure to thrive. W5 (staff) reported facility system failure regarding showers and or documentation. W5 reported staff did not report RV was without clothes to change into. No documentation of showers or body audits was found between January 1 and January 31st. Body audits up to the aforementioned time indicated RV's skin was improving or at the same level except for a rash on RV's forearms. Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000802600,385225,NF,1/9/2013,"Resident 1 was a long term resident with multiple diagnoses including osteoporosis, left knee replacement and dementia. Resident's care plan of 11/6/2012 indicated extensive assistance for transfers using a sit to stand lift, fall risk and bruising/bleeding risk were identified. Staff 2 and 6 indicated the resident was confused, but capable of expressing his/her needs. Staff 7 attempted a pivot transfer and lowered the resident to the floor when the resident's legs gave out. Staff 7 reported the resident told them he/she could assist the resident to scoot into the wheel chair. Staff 7 admitted not working with the resident before; not checking the Kardex ( kept at the nurses station); believed the resident was alert and oriented; and believed what the resident said. The resident initially did not exhibit pain or signs of injury. The resident was transferred back and forth in the day and later developed pain and leg swelling. A subsequent x-ray confirmed a fracture. Given the resident's diagnoses and no immediate evidence of injury it is inconclusive exactly when the resident sustained the fracture. The facility is looking to place in room care plans. Staff 7 received further counseling. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Not Substantiated,Substantiated, +MM132041,385225,NF,12/27/2012,The complainant voiced concern regarding inappropriate use of a wander guard for RV1 and RV2 which potentially causes seclusion. The facility failed to thoroughly assess RV1's and RV2's need for a wander guard. The facility placed RV2's wander guard at witnesses request; not necessarily because RV2 attempted to elope. Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +MM133241,385225,NF,5/15/2013,The facility accepted faxed instructions regarding a resident ordered procedure. The fax instruction did not correlate to the resident physician orders. Staff failed to obtain physician order to avoid cancellation of a procedure and or possible risk for harm to the resident. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +MM145945,385225,NF,1/24/2014,"RV was admitted 1/16/204 with an infection, a PICC line and antibiotic orders. RV was unable to give relevant information regarding the medication he/she received. W9 signed he/she administered the once a day antibiotic, went to give the medication, became side tracked and gave the medication later than the usual 7:30 to 8:00 A.M time frame. The once a day antibiotic order did not specify a time to be given, but standard of practice would be to give the medication at the same time each day. Reviewer notes the usual standard of practice is to sign a medication as given after the medication is actually given. The facility's medication practice was flawed on the day in question and RV received the antibiotic late. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000881700,385225,NF,3/10/2014,"Resident 1 was admitted with CHF. Resident assessment indicated assistance with ADLs. The resident care plan noted showers and the January, February and March ADL flow sheets reveal the showers were not always initialed. Based on interview and resident record , it was determined the facility failed to ensure sufficient staffing to meet the minimum C.N.A. to resident ratio as directed in the OAR. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +MM147040A,385225,NF,4/23/2014,"Witnesses and RP2 give different statements regarding RP2's care. RP2 denies roughness, but some witnesses report roughness when RP2 turns them while others state they want RP2 to turn them fast. A majority of witnesses reported RP2 could be ""grumpy"" and evidence supports RP2 failed to treat residents with all due respect regarding their choice of treatment. Evidence is insufficient to support neglect of care or physical abuse. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000912500,385225,NF,8/1/2014,"Evidence and interviews indicated facility failure to provide an environment free of illegal substances and drug paraphernalia for Resident #1. Resident #1 was treated in the hospital for septic thrombophlebitis and was at risk for injury, infection and overdose. Other facility residents were at risk of exposure and injury from illegal drug use. The facility failure to provide adequate care and services related to resident's safety is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000912501,385225,NF,8/1/2014,"Evidence and interviews indicated facility failure to ensure new pressure ulcers did not develop for Resident #1. Resident #1 developed a right ischial (bony prominence on lower buttocks) ulcer and a right ankle ulcer that were not discovered until they had 100% necrotic dead tissue and were unstageable. Resident #1 also sustained penile erosion related to pressure from urinary (Foley) catheter tubing and abrasions on the left out foot and toes. The facility failure to provide Resident #1 adequate care and services related to Resident #1's safety is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +MM149106,385225,NF,10/26/2014,"Based on evidence and interviews it was determined the facility failed to ensure Resident #1_x001A_s safety regarding Resident #1_x001A_s known behavior to attempt leaving the facility without assistance. On or about 10/26/2014 Resident #1 left the facility while another person was entering or exiting the facility and Resident #1 sustained a fall resulting in a fractured left hip. The facility failure to ensure Resident #1_x001A_s safety and provide adequate interventions resulting in Resident #1 sustaining a fractured left hip is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +MM147549,385225,NF,6/24/2014,Evidence and interviews indicated facility failure to protect residents from inappropriate sexual contact related to 6/24/2014 circumstances between Resident #1 and Resident #2. Resident #2 grabbed Resident #1's arm and would not let go until a caregiver removed Resident #2's hand. Resident #2 placed her/his hand on Resident #1's thigh and began rubbing the resident's thigh. Resident #2's inappropriate behavior toward other residents was documented in a 2/3/14 care plan entry. The Facility failure to provide adequate interventions with Resident #2's behavior resulting in Resident #2's behavior escalating and negatively affecting Resident #1 is a violation of resident rights are considered neglect of care and constitutes abuse.,2,,Substantiated,Substantiated,Neglect +MM149153,385225,NF,11/3/2014,Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 and Resident #2 related to adequate care planning for behaviors and resident safety.,2,,Not Substantiated,Substantiated, +OR0000924200,385225,NF,9/26/2014,"Evidence and interviews indicated facility failure to act timely for Resident #2's change of condition in a pressure ulcer. The facility failure to act timely regarding Resident #2's change in medical condition resulting in Resident #2 requiring hospitalization and a blood transfusion are violations of resident rights, are considered neglect of care and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000941100,385225,NF,12/18/2014,"Evidence and interviews indicated facility failure to follow care plan interventions for a mechanical transfer for Resident #3. The facility failure to provide Resident #3 adequate care and services related to a fall regarding a mechanical lift resulting in Resident #3 sustaining a fractured humerus of the right leg are violations of resident rights, are considered neglect of care and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +OR0000955000,385225,NF,3/13/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to resident safety. The facility failure to ensure adequate care and safety interventions were in place resulting in Resident #1 sustaining a fall with a fractured hip requiring hospitalization are violations of resident rights, are considered neglect of care and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are enclosed.",3,,Substantiated,Substantiated,Verbal/Mental abuse +OR0000955001,385225,NF,3/13/2015,"Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to ensuring the resident_x001A_s care plan was updated to include fall intervention. The facility failure to ensure adequate care plan interventions were in place resulting in Resident #1 sustaining a fall with a fractured hip requiring hospitalization are violations of resident rights, are considered neglect of care and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are enclosed.",3,,Substantiated,Substantiated,Neglect +OR0000960900,385225,NF,4/2/2015,"Evidence and interviews indicated the facility failed to adequately assess and monitor Resident #2's change of medical condition. The facility failed to place Resident #2 on alert charting when she/he sustained a temperature of 101 degrees most of the 3/5/2015 morning shift with no relief from as needed Tylenol. March 5, 2015 nursing notes written at 1:20 pm indicated Resident #2, ""_x001A_asked to be sent to the local hospital via ambulance with complaints of fever 101 degrees, chills and nausea since 6:00 am PRN Tylenol given with no results_x001A_"" The facility failure to adequately assess Resident #2's change in medical condition resulting in Resident #2's medical condition worsening is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,250,Substantiated,Substantiated,Neglect +MM145847,385225,NF,1/20/2014,"Evidence and interviews failed to indicate facility failure to provide a safe environment related to circumstances where Resident #2 wandered into Resident #1's room, touching Resident #1 and startling her/him. After the incident, the facility added a Velcro stop sign on Resident #1's door.",0,,Not Substantiated,Substantiated, +MM151702,385225,NF,6/15/2015,"Evidence and interviews indicated facility failure to assure Resident #1 did not leave the facility without assistance. Resident #1 was an elopement risk and interventions included a Wander Guard bracelet. On 6/20/2015, Resident #1 removed her/his Wander Guard bracelet and left the facility unassisted, without injury.",2,,Not Substantiated,Substantiated, +BC134877,385228,NF,10/12/2013,"Evidence and interviews indicated facility failure to provide Resident #1 timely assistance with mobility when Resident #1 asked for assistance with positioning in bed. Resident #1 said she/he was ""upset and angry"" with the care assistance provided by facility staff in response to her/his request for assistance.",2,,Not Substantiated,Substantiated, +OR0000978301,385228,NF,6/29/2015,"Evidence and interviews indicated facility failure to administer Resident #1's medication according to physician orders placing Resident #1 at increased risk for adverse medication reactions related to a medication error on or about 5/28/2015. In addition, evidence and interviews indicated facility failure to administer Resident #4's medication according to physician orders placing Resident #r at risk for adverse medication reactions related to a medication error on or about 6/11/2015. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +ES105938A,385229,NF,12/13/2010,Resident #1's 10/21/2010 care plan specified she/he required two-person assistance for all repositioning; staff were to allow Resident #1 to make daily personal care decisions. RP2 (CNA) attempted to reposition Resident #1 in bed on 12/13/2010 when Resident #1 did not want to be turned. Witness #1 said Resident #1 was emotionally upset by RP2's actions and Resident #1 asked that RP2 not be allowed in her/his room in the future.,2,0,Not Substantiated,Substantiated, +ES120597,385229,NF,7/17/2012,Evidence and interviews indicated facility failure to provide an adequate medication system for Resident #1 and Resident #2. Resident #1 was discharged from the facility on or about 07/17/2012. Resident #1 was discharged without all of her/his PRN medication and the facility erroneously sent some of Resident #2's medications with Resident #1 at the time of Resident #1's discharge.,2,0,Not Substantiated,Substantiated, +ES132580,385229,NF,3/4/2013,"Evidence and interviews indicated Resident #1 was care planned to receive toileting assistance every two hours_x001A_""Check and change if incontinent with thorough pericare_x001A_"" On 03/04/2013 Resident #1 was found soaked in urine with her/his clothing and wheelchair cushion saturated in urine. Resident #1 said she/he was ""uncomfortable"" and in pain after sitting in urine. The facility failure to provide Resident #1 with adequate toileting assistance resulting in Resident #1 sustaining painful raw skin and unreasonable discomfort is a violation of resident rights, considered neglect of care, and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +OR0000909800,385229,NF,7/17/2014,Evidence and interviews indicated facility failure to follow witness #1's (Physician) orders for weekly laboratory tests and follow-up clinical visits for Resident #2 placing Resident #2 at risk for unmet needs. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +ES150882,385229,NF,3/28/2015,Evidence and interviews indicated RP2 (Licensed nurse) failed to provide Resident #1 adequate wound care and services on or about 5/19/2015. RP2_x001A_s failure to provide Resident #1 adequate wound care and services placed Resident #1 at risk of harm from infection.,2,,Not Substantiated,Substantiated, +ES153705,385229,NF,11/23/2015,"Evidence and interviews indicated facility failure to provide adequate care and coordination of medical treatment services for Resident #1 related to a chronic skin condition of Resident #1's legs. Evidence and interviews indicated facility failure to adequately assess, intervene, and coordinate wound care for Resident #1's chronic health condition placing Resident #1 at risk of further complications. In addition, there was no documentation Resident #1 received a 11/10/2015 treatment as ordered for Resident #1's leg condition.",3,250,Not Substantiated,Substantiated, +ES164308,385229,NF,12/31/2015,"Evidence and interviews indicated facility failure to protect Resident #1 and other facility residents from the mismanagement of resident money when RP2 collected cash for charitable toy donation cause. The facility failure to ensure adequate record keeping and protection of resident money is a violation of resident rights, considered financial exploitation, and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +RD121763B,385230,NF,10/24/2012,RV2 was not checked/toileted prior to his/her appointment. RV2 has some incontinence on days he/she is toileted. Evidence is not conclusive RV2 would not have been incontinent had he/she been toileted prior to his/her appointment. RV2 did not receive timely care as the care plan called for. Facility staffing was an issue at the time of the incident.,2,0,Not Substantiated,Substantiated, +OR0000791500,385230,NF,10/26/2012,"Resident 1 was admitted 9/6/2012 with diagnoses including osteoporosis, oxygen dependency, end stage renal disease and fractures. Resident's 9/6/2012 care plan indicated impaired decision making and use of a boot to the right foot at all times. On 9/18/2012 during a wheel chair transfer the resident's right foot came down to the floor and his/her leg bent beneath the wheel chair. The resident's care plan was changed to use of leg rests at all times. Staff did not anticipate the incident. Staff 8 did not immediately report the incident; believed the resident was not injured. On 9/14/2012 family and the physician were notified as the resident began to experience pain. Staff indicated the resident could experience pain, but did not like to bother people so rarely asked for what he/she needed. Relevant portions of the survey are attached. A civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +OR0000791504,385230,NF,10/26/2012,"Resident 1 was admitted 9/6/2012 with diagnoses including osteoporosis, oxygen dependency, end stage renal disease and fractures. The facility failed to ensure physician orders for blood sugar reporting parameters were followed. Four low blood sugars and one high blood sugar were not reported to the physician. Additionally the resident was not appropriately dressed to leave the facility in cold weather. On 10/23/2012 Resident 1 was sent to dialysis without a coat and no shoes; only slippers. The outside temperature was 28 degrees. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000791505,385230,NF,10/26/2012,"Resident 1 was admitted 9/6/2012 with diagnoses including osteoporosis, oxygen dependency, end stage renal disease and fractures. Resident 1 sustained a skin tear and alrge bruised area to the back without indication of cause or preventive measures. The injuries were of unknown nature and not thoroughly investigated by the facility. Staff 2 (DNS) indicated there were no incident reports and no investigation or documentation in the nurse alert charting notebook. Relevant portions of the survey are attached. An Oregon Admisntrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000791507,385230,NF,10/26/2012,"Resident 1 was admitted 9/6/2012 with diagnoses including osteoporosis, oxygen dependency, end stage renal disease and fractures. The facility failed to insure Resident 1 was appropriately dressed to leave the facility in cold weather. On 10/23/2012 resident was sent to dialysis without a coat or shoes/slippers; the temperature was 28 degrees. The resident did have socks on. Evidence is inconclusive if Resident 1 was covered with a blanket. The resident was at risk for being cold and uncomfortable. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +RD132698,385230,NF,2/11/2013,"RV was admitted the morning of 2/11/2013 for a short term stay. On 2/11/2013 at approximately 3:00 P.M. RP2 assisted RV to the commode, RV urinated on the floor in front of the commode and reported ""feels urine got on RV's socks, but RP2 failed to clean RV's feet"" when sock were replaced. RP2 believed RV's feet did not get wet with urine. RP2 sprayed disinfectant on the floor, but failed to return in a timely manner to mop up the floor. Witnesses reported the disinfectant has a strong odor. RV did not sustain known negative effects, but was not treated with all due respect when his/her feet were not wiped or the floor cleaned in a timely manner. RP2 received further re-education.",2,0,Not Substantiated,Substantiated, +RD135026B,385230,NF,9/13/2013,RV's care plan failed to address RV's combative behavior. RV's care plan was not specific to RV's inability to use his/her left arm. The incomplete care plan attributive to negative interaction with between RV and RP2. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000895500,385230,NF,5/9/2014,"Resident 14 is a long time resident with diagnoses including Parkinson. Resident's June 2014 physician orders included administering medication, fiber source and water through resident's G tube. The orders included checking every 8 hours for placement and residual. On 6/5/14 Staff 3 initial prior to 12:30 P.M. for a 2:00 P.M. and 4:00 P.M. medication /residuals. Staff 3's actions placed resident at risk for harm and indicate poor standard of professional practice. Staff failed to ensure Resident 1's care, as well as Resident 5's care was properly performed placing residents at risk for harm. Staff 9 failed to provide professional standard of care in regards to infection control and medication delivery to Resident 5. On 6/6/2014 surveyor(s) observed Staff 10 failure to maintain good infection control when Resident 3's G Tube plug made contact with resident clothing, etc. and staff reinserted the plug without properly cleaning the plug. Relevant portions of the survey are attached. Enforcement was recommended. Oregon Administrative rules were violated.",2,,Not Substantiated,Substantiated, +RD149683A,385230,NF,12/21/2014,"On or about December 20, 2014 facility staff failed to promptly respond to RV1's call light and or timely assist RV1 to toilet resulting in RV1 soiling self and his/her bedding. W3 reported coming to work around 10:00 P.M. and six residents had their call light on. W3 checked on RV1, but went to assist other residents first; and returned to find RV1 had urinated and soiled self. RV1's call light call log showed failure to respond to RV1's call light for over 18 minutes on 12/20/2014; this is not counting the additional time W3 was out of RV1's room. The facility failure and neglect to timely toilet RV1; and honor RV1's choice to toilet timely resulted in RV1's soiling self; and ultimately resulted in RV1's loss of dignity. + + + +Although W3 reported the facility was at Oregon staffing guidelines. The Oregon Administrative Rule for minimum staffing requires that there be sufficient nursing personnel to meet the services needs of the residents. The resident's needs must be the primary consideration in determining the number and category of nursing staff. The facility neglect constitutes abuse. Oregon Administrative Rule violations occurred.",3,300,Substantiated,Substantiated,Neglect +RD149683C,385230,NF,12/21/2014,The complainant reported staff failure to promptly schedule a chest x-ray ordered by the physician after RV2 sustained a change in condition. Witness interview and documentation review noted resident change of condition and physician notification at multiple times with physician call back with orders at 4:15 A.M. on 12/21/2014. At 4:45 A.M. the physician called again with new orders for a chest x-ray as soon as possible. RV's physician arrived later and made arrangements to transport RV. Staff called the paramedics who arrived within 10 minutes and transferred RV for the chest x-ray. Staff failed to make timely arrangements to transport RV for the chest x-ray. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +RD150743,385230,NF,2/26/2015,W5 (family) requested RV receive a shower no matter what as RV had odor/dirty hair. W2 and W3 asked W4 (LN) and was told to go ahead with the shower. RV was saying no/slapping at staff. RV's right to refuse care and be given choice in his/her care was denied. Staff had tried different options to help RV accept a shower prior to this event. RV's care plan was adjusted to RV receiving a bath during massage. Staff received further in-service regarding resident rights. The resident right of choice was denied despite the resident's objection resulting in a significant loss of dignity which constitutes abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +GP105329,385232,NF,9/24/2010,"RV reported RP2 had mistreated RV one day, does not want RP2 to lose his/her job and RV does not live in the facility anymore. RP2 denies calling RV a dirty nasty man/woman. RP2 reported asking RV to turn down the TV level 3 times as it was at ""50"", reported being calm and explaining other residents were still sleeping at 5:00 A.M. W3 gave a different account of the incident than RP2. W3 reported RV was in tears. W4 was unable to give specific to the event other than hearing yelling. At minimum RP2 was yelling at RV. RP2 failed to treat RV with all due respect and dignity.",2,0,Not Substantiated,Substantiated, +GP116296,385232,NF,2/5/2011,"On 2/4/11 staff observed RP2's behavior change, including slurred words and bumping into things. W3 drove RP2 home. On 2/5/11 at 7:30 A.M. W3 checked on RP2 and RP2 ""appeared ok"", but later ""appeared"" lethargic, having difficulty walking and bumping into things. W3 requested to take RP2 to the urgent care, but RP2 refused. W3 called in W2 to replace RP2. W2 had observed RP2 falling asleep at the nurses station on 2/4/11; and later the same day swaying and slurring words. On 2/5/11 W2 observed RP2 had written he/she gave RV 1 mg of a medication when0.25 mg was ordered. RV did not sustain any notable outcomes from the medication error. W2 found discrepancies in the narcotic's book made by RP2. The facility failed to ensure a safe environment resulting in a known medication error and documentation errors.",2,0,Not Substantiated,Substantiated, +GP118473,385232,NF,11/16/2011,RP2 raised his/her voice to RV. W1 and RP2 gave differing accounts regarding RV and RP2's physical contact. RP2 reported raising his/her hands to protect self and denied holding RV's hands. RP2 failed to treat RV with all due respect by raising his/her voice. Evidence is inconclusive exactly how RV acquired some hand bruising. RP2 will no longer work with RV and W1. W3 identified W1's annoyance with RV as a possible trigger for RV's behavior and this should be addressed in RV's care plan.,2,0,Not Substantiated,Substantiated, +OR0000900102,385232,NF,5/29/2014,Resident 1 was admitted May 2014 with multiple diagnoses. The resident had a history of falls and altered mental status. Staff 4 reported the resident bed alarm was turned off when staff entered resident's room. Staff 4 indicated he/she failed to ensure the alarm was turned on. Staff 9 reported he/she was sure the alarm was on before leaving his/her shift. The facility failed to ensure the resident's care plan was followed. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rules were violated.,2,,Not Substantiated,Substantiated, +OR0000900101,385232,NF,5/29/2014,Resident 1 was admitted May 2014 with multiple diagnoses. The resident was care planned for bathing twice a week. The resident did not receive a bath and or reassessment for bathing from 5/19 through 5/24/2014. the facility failed to provide adequate resident hygiene. The resident was placed at risk for unmet personal care needs. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +GP148776,385232,NF,9/25/2014,"RP2 left RV alone on the commode contrary to RV's care plan instruction. RP2 reported being trained to respect RV's request to be left in privacy while on the commode. RP2 admitted not being aware of RV's care plan for attendance; reported RV has not change much since RP2 had been in the facility. RV knew RV should have used the call light, but chose not to. W3 was unaware of RV's care plan for attendance on the commode. The facility failed to provide supervision and ensure all staff followed RV's care plan resulting in a preventable fall with injury. Oregon Administrative Rules were violated.",2,,Substantiated,Substantiated,Neglect +MV129873,385233,NF,6/30/2011,"Resident #1's physician wrote an order on February 10, 20111 to give Resident #1 a pneumonia vaccine. The facility did not address the vaccine until February 24, 2011 at which time it was held because Resident #1 was being treated with antibiotics for multiple medical issues. The facility did not address the vaccine again after that date. On or about June 30, 2011 Resident #1 was admitted to the hospital with pneumonia. It is not known if the administration of the vaccine would have prevented Resident #1's subsequent pneumonia.",2,0,Not Substantiated,Substantiated,Neglect +MV145852,385233,NF,1/22/2014,"Based on evidence and interviews it was determined the facility failed to send Resident #1's PRN (as needed) pain medication with Resident #1's discharge to another facility, placing Resident #1 at risk for untimely administration of pain medication.",2,,Not Substantiated,Substantiated, +OR0000969500,385233,NF,5/14/2015,"Evidence and interviews indicated the facility failed to implement care planned safety measures for Resident #2. A 4/24/2015 fall risk evaluation for Resident #2 indicated Resident #2 was at high risk for falls. The resident_x001A_s 4/24/2015 care plan indicated, _x001A_Do not leave unsupervised in bathroom/on bedside commode._x001A_ According to 4/26/2015 progress notes, Resident #2 was found on the restroom floor guarding her/his right leg, refusing to move the leg and exclaiming, _x001A_It hurts._x001A_ The facility failure to ensure adequate fall interventions were in place resulting in Resident #2 sustaining a fall with a fractured fibula and pain are violations of resident rights, are considered neglect of care and constitute abuse. Relevant portions of the complaint report investigation are attached.",3,400,Substantiated,Substantiated,Neglect +MV152581,385233,NF,8/22/2015,"An 8/15/2015 care plan for Resident #1 indicated Resident #1 required one-person staff assistance to use the toilet and she/he was at risk for falls related to weakness. Evidence and interviews indicated facility staff assisted Resident #1 to the toilet on 8/22/2015 around noon. Resident #1 used an alert cord to request staff assistance approximately 10 minutes later. At approximately 12:50 pm facility staff went to assist Resident #1 who was still sitting on the toilet, crying and indicating she/he was in pain. The facility failure to ensure timely call light response and adequate toileting assistance, resulting in Resident #1 sustaining pain, are violations of resident rights, are considered neglect of care, and constitute abuse.",2,250,Substantiated,Substantiated,Neglect +OR0000657900,385234,NF,12/29/2010,"The facility failed to ensure that Resident #1 did not develop pressure sores when this was clinically avoidable. After Resident #1 developed a pressure sore the facility failed to ensure Resident #1 received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Federal penalty recommended; relevant portions of the survey report are attached.",3,2500,Substantiated,Substantiated,Neglect +SV117556,385234,NF,7/17/2011,"On 07/17/2011 both Resident #1 and Resident #2 made complaints about the way RP2 (CNA) provided care. Resident #1 said RP2 ""mopped"" Resident #1's face with a washcloth, turned her/him too fast and pulled on her/his arm in the process. Resident #2 said RP2 was a little rough at times, RP2 rolled her/him too fast, too hard and RP2 was in too big of a hurry. Facility failed to assure resident rights and assure residents dignity.",2,0,Not Substantiated,Substantiated, +MV121656A,385234,NF,11/16/2012,"Evidence and interviews indicated facility failed to ensure Resident #1 received care services while being treated with consideration, respect and dignity.",2,0,Not Substantiated,Substantiated, +MV121656B,385234,NF,11/16/2012,"Evidence and interviews indicated facility failed to ensure Resident #2 received care services while being treated with consideration, respect and dignity.",2,0,Not Substantiated,Substantiated, +MV121489,385234,NF,10/24/2012,On or about 10/24/2012 residents reported concerns about rough care assistance. Evidence and interviews indicated facility failure to ensure adequate care assistance for residents.,2,0,Not Substantiated,Substantiated,Neglect +OR0000809100,385234,NF,2/1/2013,Evidence and interviews indicated facility failure to ensure Resident #1's gait belt was in place while receiving transfer assistance on 11/16/2012. Resident #1's legs gave out; she/he fell to the floor and sustained a fracture. Relevant portions of complaint report investigation are attached; federal penalty recommended.,3,0,Substantiated,Substantiated,Neglect +OR0000834701,385234,NF,6/11/2013,"Evidence and interviews indicated facility failure to immediately notify Resident #1's family member and physician of an injury. This failure placed Resident #1 at risk of not receiving timely treatment and the family members at risk of being unable to participate in health decisions. Evidence and interviews also indicated facility failure to maintain accurate and complete clinical records for Resident #1, placing Resident #1 at risk for an inaccurate and incomplete reflection of her/his health care and treatment status. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +MV135153A,385234,NF,11/21/2013,Based on evidence and interviews it was determined the facility failed to comply with discharge orders related to Resident #1's discharge from the facility. The Facility failure to discharge Resident #1 with prescribed pain medication placed Resident #1 at risk of serious harm.,3,200,Not Substantiated,Substantiated, +BH104215,385236,NF,5/7/2010,"RP2, RP3 and RP4, as well as, other staff knew a box with multiple medications including narcotics was kept on a shelf in RP2's office. Staff reported being instructed to sign out medication if needed. The facility DNS and administrator believed the medication was destroyed as policy/procedure directed. No evidence was found to support a negative outcome to a resident; either physically or financially. The facility failed to secure narcotics resulting in potential harm for residents.",2,200,Not Substantiated,Substantiated, +BH146571A,385236,NF,3/12/2014,"RV and the complainant reported RV had an infection in the Peri area on admission (3/12/2014), staff failed to treat it a appropriately. Staff failed to promptly request treatment. While RV received some treatment it was not properly treated until the resident was sent to the hospital for unrelated diagnoses. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BH146571B,385236,NF,3/12/2014,"RV received medication that was discontinued RV did not sustain a negative outcome, but was at risk for harm. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000890602,385236,NF,4/14/2014,"Resident 1 was admitted March 2014 with diagnoses including stroke. Resident assessment and care plan f 3/9/2014 indicated resident required two staff for transfers. The resident care plan noted two person assist with dressing, bed mobility and toileting. Nursing notes of 4/15/2014 noted a 5 cm abrasion to resident's left mid calf. The origin of the injury is unknown, but may have occurred during a transfer. Staff failed to complete a timely investigation of the injury.. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC151242,385236,NF,2/13/2015,"RV was admitted 12/24/2014 following a nine day hospital stay. RV reported not receiving medication timely and being in pain. Witnesses reported faxing physician orders to the pharmacy on 12/24/2014, reported receiving a call from the pharmacy on 12/25/2014 regarding incomplete orders, reported medication can be taken from the E-Kit using proper process and reported no medication was taken from the E-kit until 12/25/2014. Witnesses reported it can take longer to receive medication from the pharmacy and or contact a pharmacist for authorization on weekends and holidays. The facility failed to timely contact the pharmacy and or a pharmacist to ensure physician orders were properly received by the pharmacy, medication was timely delivered to the facility and or taken from the E-Kit; and medication was given timely to RV resulting in RV not receiving his/her Lidocaine pain patch or Acyclovir until late afternoon on 12/25/2014. RV sustained unnecessary pain from not receiving the Lidocaine patch timely. The facility failure constitutes neglect and abuse. Oregon Administrative Rule Violations occurred.",3,400,Substantiated,Substantiated,Neglect +OR0000666500,385237,NF,2/4/2011,Resident 1 was admitted early 2010 with diagnoses including chronic pain. On 5/5/10 Resident 1's physician ordered MS Contin on a daily basis and PRN Dilaudid. Resident 1 did not receive all medication as ordered . Resident 1 did receive Dilaudid with good pain relief at times he/she missed receiving the MS Contin. Staff did notify the on call physician and received orders to increase the Dilaudid. Staff failed to obtain a timely order to refill Resident 1's MS Contin between denial on 1/13/11 and running out of medication on 1/15/11. Resident 1 was transferred to the hospital for treatment despite receiving the narcotic Dilaudid. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000645900,385239,NF,11/9/2010,"According to a facility incident report dated 11/5/2010, Resident #1 was in the bathroom with staff #9 (CNA) present. After staff #9 assisted Resident #1 to stand Resident #1 became too weak to continue standing and Resident #1 fell to the floor. Resident #1 was sent to the hospital and a fractured leg was confirmed. Staff #9 had not placed a gait belt around Resident #1, per facility policy. Federal civil penalty recommended; relevant portions of the survey report are attached.",3,0,Substantiated,Substantiated,Neglect +NB105691,385239,NF,11/16/2010,"On November 18, 2010 around noon, Resident #1 went to the nurse_x001A_s station and requested assistance with incontinence. Staff provided Resident #1 said incontinence assistance at approximately 2:45 pm. Resident #1 said she/he was uncomfortable from not receiving timely assistance.",2,300,Substantiated,Substantiated,Neglect +OR0000737800,385239,NF,1/4/2012,"Evidence and interviews indicated facility failure to ensure that Resident #2 received the necessary treatment and services to promote healing of pressure sores, prevent infection and prevent new sores from developing when this was clinically avoidable.",4,2500,Substantiated,Substantiated,Neglect +OR0000772100,385239,NF,7/13/2012,Evidence and interviews indicated facility failure to provide dressing changes according to standards of practice for Resident #1. Resident #1's dressing for a right groin wound was not assessed or changed daily. Federal penalty recommended; relevant portions of the complaint report investigation are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000817300,385239,NF,3/8/2013,Evidence and interviews indicated facility failure to provide adequate supervision for Resident #1 related to falls. The facility failed to ensure that Resident #1 received adequate care and services related to fall interventions resulting in Resident #1 sustaining a fall with injuries. This failure is considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.,3,400,Substantiated,Substantiated,Neglect +NB133273,385239,NF,4/17/2012,"Evidence and interviews indicated facility failure to follow physician orders to weigh Resident #1 daily. Resident #1's physician was to be notified of any increases in weight of three pounds in one day or five pounds in one week. The facility failed to notify Resident #1's physician until Resident #1 sustained a 14 pound weight gain from April 11 through April 15, 2012. The facility failed to follow physicians_x001A_ orders resulting in Resident #1 needing hospitalization is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,450,Substantiated,Substantiated,Neglect +OR0000879401,385239,NF,2/24/2014,"Evidence and interviews indicated facility failure to complete a comprehensive assessment related to the increased risk of pressure ulcers for Resident #3 who had an immobilizer brace. In addition, evidence and interviews indicated facility failure to properly fit and position Resident #3_x001A_s orthotic device and routinely evaluate for pressure areas. In addition, evidence and interviews indicated facility failure to ensure Resident #3's immobilizer brace was properly applied, securely fit and cleaned adequately. Resident #3 developed a Stage IV pressure ulcer (with tendons visible) on the left Achilles tendon related to the immobilizer. The Facility failure to ensure Resident #3 received adequate care and services related to the use of an immobilizer brace resulting in Resident #3 sustaining a Stage IV pressure ulcer are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,2500,Substantiated,Substantiated,Neglect +OR0000880600,385239,NF,2/28/2014,"Evidence and interviews indicated facility failure to ensure Resident #1 received adequate assessment, monitoring and placement of Foely (urinary) catheter tubing. The Facility failure to ensure Resident #1 received adequate care and services related to skin breakdown resulting in Resident #1 sustaining necrosis and erosion where a catheter tube was inserted are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,2500,Substantiated,Substantiated,Neglect +OR0000879400,385239,NF,2/24/2014,"Evidence and interviews indicated facility failure to complete a comprehensive assessment of Resident #3 regarding the use of side rails with a low air loss and alternating pressure mattress. The facility failure to ensure a safe environment for Resident #3 resulting in Resident #3 falling from her/his bed and requiring hospital treatment are violations of resident rights, are considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,400,Substantiated,Substantiated,Neglect +NB147947,385239,NF,7/17/2014,"Evidence and interviews indicated facility failure to provide Resident #1 adequate pain medication administration. Resident #1 was admitted to the facility from the hospital following surgery on 7/17/2014 at 2 pm. Resident #1 had medication orders for pain, anxiety, insomnia and blood sugar stabilization. RP2 (licensed nurse) provided Resident #1 with some of the ordered medication on 7/17/2014, however she/he failed to check the order and determine Resident #1_x001A_s physician had approved additional PRN (as needed) doses of pain medication to be administered. Resident #1 said she/he had a, _x001A_very difficult time_x001A_ with her/his pain and anxiety the first night at the facility because she/he was not given the ordered medication. The Facility failure to ensure Resident #1 received medication as ordered resulting in Resident #1_x001A_s continued pain and discomfort are violations of resident rights, are considered neglect of care and constitutes abuse. Enclosure: Oregon State Board of Nursing Policy on Pain Management Authority for Approval [ORS 678.010(7), OAR 851-045-0030 through 0060] Approval [Approved by Board April, 2012].",3,400,Substantiated,Substantiated,Neglect +NB150154,385239,NF,2/6/2015,Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to timely assistance with Resident #1's care needs. The facility failure to provide Resident #1 adequate care and services related to timely care assistance placed Resident #1 at risk for unmet care needs.,2,,Not Substantiated,Substantiated, +NB151080,385239,NF,4/28/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from the theft of narcotic medication by RP2 (CNA). Resident #1 was discharged from the facility on 4/16/2015 and it was determined Resident #1 was short four tablets of pain medication. On 4/17/2015, RP2 was questioned, drug-tested and suspended from the facility. RP2 was found dead on 4/23/2015. The facility failure to protect Resident #1 from RP2_x001A_s financial exploitation constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +SV118415,385240,NF,11/6/2011,"W10 visited RV on 11/6/11 at approximately 1:15 P.M. and found RV with unchanged under garments and breakfast food left nest to the bed. RV is unable to give relevant information. W2 stated W10 reported to them at about 12:45 P.M. regarding RV's condition. Staff reported delivering the tray, RV began to eat and staff left. W7 reported working in the dining room in the A.M. and checking RV at 10:30 A. M., changing RV and RV refusing to let W7 take the tray. RV's bedside care plan indicated tray/meal set up and cuing. The facility is assessing practices related to meal tray handling and timeliness.",2,0,Not Substantiated,Substantiated, +OR0000679603,385240,NF,4/1/2011,"Witnesses and Resident 1 reported Resident 1 was placed on a commode chair to go into the shower across the hall from his/her room. Resident 1 reported telling staff he/she had to go to the toilet. Staff 5 does not recall toileting Resident 1. Staff reported ""probably"" telling Resident 1 he/she ""could go"", but do not remember telling Resident 1 in the hallway. Staff failed to fully explain to Resident 1 about the commode use and such failure constitutes a violation of resident rights.",2,0,Not Substantiated,Substantiated, +SV117739,385240,NF,8/6/2011,"RP2 failed to provide repositioning and incontinence care as RV's care plan indicated during RP2's 8 hour work shift. While RV did not sustain notable physical negative effects. RV was at risk for skin breakdown. Additional information provided by RP2 indicated RP2 provided minimal care, raised and lowered RV's head of the bed for easier breathing and brought food/water. RV requested a brief change and reposition around 8:45 P.M. and RP2 readied the room with linens and sought other staff for assistance. RP2 reported other staff reported they would assist when finished with their residents, but did not show by shift change. RP2 was fairly new CNA who required additional supervision to prioritize his/her duties. In addition to RV, RP2 had 9 other non ambulatory resident with five requiring two person assist for transfers. RP2 was able to assist other resident up to the dining room, etc. and kept looking in on RV. All staff on duty deny RP2 asked for assistance with RV's care, but RP2 did go to her charge nurse to report RP2 had not taken a break and again to seek assistance, but RP2 found the nurse busy with a resident. The facility failed to achieve adequate staff supervision to ensure RV received care as planned.",3,300,Substantiated,Substantiated,Neglect +SV118122,385240,NF,9/29/2011,"Money was taken from RV's room. RV reported this was first time event and no one had offered RV the use of the facility safe, but staff reported RV was encouraged to place money in the safe. Evidence is inconclusive who may have taken the money, but the facility failed to provide a secure environment for RV's money. The facility replaced RV's money.",2,0,Substantiated,Substantiated,Financial abuse +MV117943,385240,NF,9/3/2011,"RV resided in the facility three days before staff were alerted by a visitor that RV had a Fentanyl patch on RV's back. Witnesses reported on day three RV was in the same clothing as he/she was in on admission; clothing was soiled with feces. Witnesses reported staff failure to respond to RV's call light in a timely manner to assist RV to the toilet or assist when RV fell out of bed. W5 reported staff failure to stop oxycodone when W5 told them RV was allergic to morphine. Document review found RV received medication as ordered. Nursing notes of 9/6/2011 reveal staff finding RV on the floor without the call light being initiated. RV's family and physician were notified with RV transferred for further evaluation. While RV's care plan called for fall risk interventions, these were not in place at the time RV fell in the bathroom. Review finds the facility failed to re-evaluate RV when RV showed cognitive decline within the first 24 hours. The facility failed to provide a safe environment resulting in abuse ( neglect of care) and violation of Oregon Administrative Rule.",2,0,Substantiated,Substantiated,Neglect +MV121466,385240,NF,10/12/2012,"Facility staff failed to ensure RV was provided full privacy while using a bed pan. RV does not recall who was assisting him/her, reported everyone was nice and stated sometimes they are in a hurry. W1 reported finding RV on the bed pan with bottom half exposed; privacy curtain was not fully closed and sheet was at the bottom of the bed. RP2 reported the privacy curtain is difficult to move and not wide enough to pull closed without leaving gaps. The facility provided further in-service on privacy and dignity.",2,0,Not Substantiated,Substantiated, +MV132463,385240,NF,12/12/2012,"RP2 failed to treat RV with all due respect when RV raised his/her fists to RP2 and yelled at RP2. W2 reported RP2 ""yelled"" back at RV and told RV that RP2 would call the police if RV hit him/her (RP2). The facility provided prompt intervention by suspending RP2 and reporting RP2's behavior to OSBN. RP2's behavior represents less than stellar standard of professional behavior. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +WB149000,385240,NF,10/16/2014,"RV reported RP2 has said ""mean things to RV"" and RV is afraid of RP2. W2 and 3 deny RP2 has said mean things to them or heard complaints by others per W3. W5 was in RV's room at the time RP2 called RV names like ""pussy"" and ""mamma's boy"". W5 reported writing down the event and giving it to management later. RP2 reported someone must have got things mixed up. RP2 remembered RV saying RV was a ""pussy"" and RP2 told RV that RV was not a ""wussy"". The investigator observed RV to be more serious when the investigator questioned the RV about the event. RV's service plan notes staff to converse with RV during care. RP2 failed to treat RV with all due respect; calling RV a ""pussy"" or a ""wussy"". The facility provided prompt intervention to promote a safe environment. An Oregon Administrative Rule was violated.",2,,Not Substantiated,Substantiated, +WB152524,385240,NF,4/28/2015,"Resident reported his/her purse with checks and apartment keys went missing prior to 5/4/2015; possibly 4/28/2015. Staff looked for the purse, but did not find it until August 2015. Staff believe RV laced the purse in the drawer while using the telephone in the therapy room. Witnesses report leaving a voice mail for RV that the purse was found. W4 reported RV and other residents are told to lock valuables in their safe. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +MV129961,385241,NF,4/25/2012,"Witnesses stated and written witness statements reported RP2 verbally and or emotionally abused RV1 and RV2. RV1 reported RP2 yelled at RV and made RV feel bad and unimportant, but stated no to specific allegations. RV1 agreed RP2 told RV that RP2 would be back.. Other witnesses reported RP2 told RV1 he/she ""quit crapping your pants- can't you wait until the next shift- I hate this. It's disgusting"". _x001A_ I hate old people_x001A_"" Written statement regarding RP2 threaten RV2 ""you told the State on us, didn't you? If you do that again we are going to beat you over the head with your dead leg."" Further evidence finds that RV2 liked to banter with staff. RP2 acknowledged others listening to RV2 and RP2 might misconstrue the content of their conversation.",3,0,Not Substantiated,Substantiated, +OR0000833600,385241,NF,6/7/2013,"resident 1 was admitted May 2013 with multiple diagnoses and care plan for skin at risk. Resident developed Stage II ulcers identified on 5/27/2013. staff failed to promptly follow-up a fax sent to resident's physician regarding resident care. The resident did receive care per a standing order, as well as, care without a physician signed order. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +MV135043,385241,NF,11/5/2013,Resident received medication late and was at risk for harm. The resident did not sustain known adverse reaction. The facility new medication computer system was slow. The facility has taken further measures to ensure medication will be given timely.,2,,Not Substantiated,Substantiated, +OR0000875500,385241,NF,1/29/2014,Resident 1 was admitted 12/2/2103 with multiple diagnoses including fatigue and pot surgical repair of fractures. Resident care plan dated 12/19/2013 indicated a high risk for falls with interventions including two staff assist with all transfers using a gait belt. Resident complained of upper left arm pain on 1/14 7 15/2014 with the resident reporting a fall the night of 1/14/2014. resident's roommate denied any knowledge of a fall. W1 reported resident did not fall. W1 reported the resident fell back in bed while sitting on the bed and may have perceived this as fall. W1 did fail to follow resident care plan and used a one person assist instead of a two person assist. Evidence is inconclusive whether or not the resident sustained the left distal humeral shaft fracture as the resident's hand/humerus were not x-rayed at time of the left shoulder and hip fracture. The resident received treatment as ordered. Relevant survey pages are attached. Enforcement action was taken. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +MV148225C,385241,NF,8/14/2014,W4 reported hearing RP2 threaten RV2 that he/she would hit RV2 if RV2 hit RP2. RV2 was unable to give relevant information. RP2 denied threatening RV2; told RV2 if RV2 did not stop asking for a sleeping pills then RV2 needed spanking. RP2's remarks to RV2 constitute verbal/emotional abuse. The facility provided prompt intervention to keep RV2 safe. Oregon Administrative Rule violations occurred.,3,,Not Substantiated,Substantiated,Verbal/Mental abuse +MV148225A,385241,NF,8/14/2014,"RV1 reported not liking to be ""spanked"", it was a put down, it did not hurt, told RP2 to stop and RP2 treated RV1 wrong. W3 corroborated that RP2 ""spanked"" RV1's bottom, then ""slapped RV1's belly saying you're just a fat mean (gender)"" and again slapped RV1's butt telling RV1 he/she liked it. RP2 denied ""spanking"" or ""patting"" RV1. The preponderance of evidence finds RP2 inappropriately struck RV1's bottom and stomach while making humiliating remarks regarding RV1. RP2's behavior and action constitute physical and verbal/emotional abuse. The facility provided prompt intervention to protect RV1. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Physical Abuse +OR0000969100,385241,NF,5/14/2015,"The facility failed to follow physician orders for Resident 7, 12, 32 and 57. review and interview regarding Resident 7 identified bowel care was not given per facility protocol and physician's ordered. Staff failed to notify the physician regarding no bowel movement after the 5th day. Resident 12's care plan indicated fall risk with interventions. Staff failed to in sure resident alarm was connected and functioning. Resident 32's care plan indicated skin risk, a vascular wound and a chronic right thigh wound. Record review and witness interview identified not all treatments were given as ordered in March, April and May with out documentation as to why the treatment was not given. Some staff reported not all resident refusals were documented. In March staff reported Resident wound was packed with the wrong packing material at least twice. Resident 57 was admitted in 2014 with diagnoses including weight loss. Record review and interview indicate the resident feeding tube was not flushed as ordered. Resident's July MAR indicated the resident's glucose level was not monitored as ordered and insulin was not given on three occasions. Resident's feeding tube residuals were not documented on several occasions. Relevant portions of the survey re attached. Enforcement was proposed. Oregon Administrative ;rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000969101,385241,NF,5/14/2015,"Resident 7 was a long term resident with diagnoses including a stroke. Staff 10 failed to notify the physician on 4/6/2015 when resident's toe lost Escher, drainage, redness and pain developed. The resident physician was faxed on 4/8/2015 and family was notified. Resident 12 a long time resident with multiple diagnoses was sent to the hospital three different times without family being notified timely. Staff failed to notify the physician on two occasions when the resident had no bowel movement for 6 days.res 58's family was not notified and or documentation the family was notified of resident's change of condition on a number of occasions. Relevant portions of the survey re attached. Enforcement was recommended. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000969102,385241,NF,5/14/2015,"Resident 7 was a long term resident with diagnoses including a stroke. Staff 10 failed to notify the physician on 4/6/2015 when resident's toe lost Escher, drainage, redness and pain developed. The resident physician was faxed on 4/8/2015 and family was notified. Resident 12 a long time resident with multiple diagnoses was sent to the hospital three different times without family being notified timely. Staff failed to notify the physician on two occasions when the resident had no bowel movement for 6 days.res 58's family was not notified and or documentation the family was notified of resident's change of condition on a number of occasions. Relevant portions of the survey re attached. Enforcement was recommended. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000969104,385241,NF,5/14/2015,"Based on surveyor observation, interview and record review it was determined the facility failed to follow physician orders for Resident 7, 12, 32 and 57. the reader is referred to the first allegation and LOD OR0000969100 for details and the attached 2567. The facility failed to in sure Resident 49's medical record was complete. Staff failed to provide PRN bowel care which placed the resident at risk for harm. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000969105,385241,NF,5/14/2015,"Based on observation, interview and record review it was determined the facility failed to in sure a resident was free from unnecessary medication and the resident had adequate indications of use of the medications. Resident 49 received multiple medications between 8:47 and 9:00 A.M. on 8/3/2015 without indication for use or other non pharmalogical intervention being utilized first. All the medications used had potential for adverse reaction and potential drug to drug interaction. The resident became weak, laid down, napped and required use of a wheel chair for lunch. At 3:00 P.M. the resident was found slumped over in the wheel chair and unresponsive. Resident's Zyprexa was increased, but Staff 3 was unaware why the medication was increased. The resident sustained an adverse reaction when the resident was simultaneously receiving an antidepressant and other medication. Relevant portions of the survey are attached. Enforcement was initiated. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0001030200,385241,NF,11/17/2015,"Resident 1 was a long term resident of the facility with diagnoses including anxiety, episodes of vomiting and diarrhea and a drop in blood pressure. Per interview and record review the facility failed to ensure the resident's physician was notified of the resident changes. Resident 1 was given IV fluids by W6 without a physician order. The resident was placed at risk for harm a nursing progress note dated 10/26/2015 at 3:50 P.M. indicated a verbal order was received from the physician approving IV fluids that were previously administered by W6. Per record review it was determined the resident's bowel protocol was not followed placing the resident at risk for harm. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0001030201,385241,NF,11/17/2015,"Resident 1 was a long term resident of the facility with diagnoses including anxiety, episodes of vomiting and diarrhea and a drop in blood pressure. Per interview and record review the facility failed to ensure the resident's physician was notified of the resident changes. Resident's physician was not notified of the resident going without a bowel movement at day five and day six. Per record review it was determined the resident's bowel protocol was not followed placing the resident at risk for harm. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +AL091940A,385242,NF,8/26/2009,"Witness #2 said she/he was contacted by facility staff on December 9, 2008; facility staff reported Resident #1 was _x001A_nonresponsive._x001A_ Witness #2 suggested staff check Resident #1_x001A_s blood sugar level. Witness #2 said she/he arrived at the facility and contacted 911 when she/he saw Resident #1. Emergency response medical staff treated Resident #1 for low blood sugar. Witness #3 (administrator) said if a blood sugar level is low, 911 is contacted. Witness #3 was unable to recall who contacted 911 on December 9, 2008 regarding Resident #1_x001A_s blood sugar crisis; as it was hard to remember _x001A_events that long ago._x001A_ Facility failed to adequately intervene with Resident #1_x001A_s drop in blood sugar on December 9, 2008.",2,0,Substantiated,Substantiated,Neglect +OR0000694400,385242,NF,6/20/2011,"Interviews and documentation indicated facility failed to provide adequate bathing assistance for Resident #1, Resident #2 and Resident #3. In addition, Resident #1 was to receive weekly nail care with bathing and when soiled. June 9, 2011 documentation indicated Resident #1 was observed to be ""dirty,"" smelled, and she/he had long fingernails and toenails. Relevant portions of the survey, complaint report are attached.",2,0,Not Substantiated,Substantiated, +AL116636B,385242,NF,3/24/2011,Evidence and interviews indicated facility failure to provide physician ordered daily weights for Resident #1 from 03/24/2011 through 03/28/2011.,2,0,Not Substantiated,Substantiated, +OR0000783400,385242,NF,9/12/2012,Evidence and interviews indicated facility failure to provide Resident #1 adequate medication administration care and services resulting in Resident #1 requiring hospital treatment. Relevant portions of the complaint report investigation are attached.,3,400,Substantiated,Substantiated,Neglect +OR0000821501,385242,NF,4/2/2013,"Evidence and interviews indicated facility failure to monitor Resident #1's diabetes including dietary intake and failure to provide and document Resident #1's diabetic interventions, placing Resident #1 at risk for unmanaged diabetes. Relevant portions of the complaint report investigation are attached.",2,0,Not Substantiated,Substantiated, +OR0000821500,385242,NF,4/2/2013,"Evidence and interviews indicated facility failure to ensure Resident #1's care planned fall interventions were implemented. Resident #1 sustained a fall and required hospitalization. This failure is considered neglect of care and constitutes abuse. In addition, evidence and interviews indicated facility failure to assess the use of potential restraints and provide the risks and benefits to the responsible party related to Resident #1 and Resident #2. Federal penalty recommended; relevant portions of the complaint report investigation are attached.",3,0,Substantiated,Substantiated,Neglect +OR0000970100,385242,NF,5/18/2015,"Evidence and interviews failed to indicate facility failure to administer Resident #1's pain medication as ordered. However, an expanded record review indicated facility failure to provide Resident #3's pain medication as ordered. This placed Resident #3 at risk for adverse medication reaction. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +AL164552,385242,NF,12/4/2015,"Evidence and interviews indicated facility failure to ensure Resident #1's right to refuse care assistance and failed to ensure RP2 (CNA) and Witness #5 (CNA) treated Resident #1 with consideration, respect, and dignity while providing care assistance on or about 12/4/2015. The facility failure to assure Resident #1's rights, resulting in Resident #1's loss of dignity, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Not Substantiated,Neglect +AL164982,385242,NF,3/1/2016,"Evidence and interviews indicated facility failure to administer Resident #1's bladder spasm medication as ordered. January 27, 2016 physician orders indicated Resident #1 was ordered 200 mg bladder spasm medication as needed (PRN). However February 1, 2016 medication administration record (MAR) indicated Resident #1 was incorrectly given 200 mg bladder spasm medication daily during February 2016. A March 2016 MAR, for Resident #1 indicated Resident #1 was inaccurately administered the bladder spasm medication daily 3/1 through 3/4/2016. Resident #1 refused the bladder spasm medication 3/5 and 3/6/2016 with the medication discontinued on 3/7/2016.",2,,Not Substantiated,Substantiated, +OR0000672800,385244,NF,3/1/2011,"Evidence and interview indicated facility failure to provide the necessary care and services to prevent Resident #1 from sustaining severe burns on February 26, 2011. Federal civil money penalty recommended; relevant portions of survey report are attached.",3,0,Substantiated,Substantiated,Neglect +OR0000672801,385244,NF,3/1/2011,Evidence and interview indicated facility failure to timely provide the necessary care and services for Resident #1. Resident #1_x001A_s right leg was observed to be in contact with the baseboard heater at 11:35 pm on 2/26/2011; Resident #1 was not provided with emergency medical treatment until 11:00 am on 2/27/2011. Federal civil money penalty recommended; relevant portions of survey report are attached.,3,0,Substantiated,Substantiated,Neglect +OR0000672802,385244,NF,3/1/2011,Evidence and interviews indicated facility failure to provide an environment free of a burn hazard from the baseboard heater in Resident #1's room. Federal civil money penalty recommended; relevant portions of survey report are attached.,3,0,Substantiated,Substantiated,Neglect +TM116439,385244,NF,2/23/2011,"Resident #1 was care planned to have a fall mat next to her/his bed. On 2/23/2011 RP2 moved the floor mat when RP2 went to get the Hoyer lift. Resident #1 fell from the bed to the floor. Witness #1 said Resident #1 appeared to be in pain, so a physician was notified and pain medication was ordered for Resident #1.",2,0,Substantiated,Substantiated,Neglect +TM091231,385244,NF,6/2/2009,"On June 2, 2009 Resident #1 eloped from the facility through a door at the back of the facility; the door alarm was off. Resident #1 entered a building adjacent to the facility and subsequently fell sustaining a laceration over the left eyebrow. A civil penalty was not issued due to the extended period of time between the incident date and processing by the Department.",2,,Substantiated,Substantiated,Neglect +OR0000699400,385244,NF,7/15/2011,"Evidence and interviews indicated facility failure to provide residents (Resident #1, Resident #5 and Resident #9) adequate care and services regarding changes in their conditions. Evidence and interviews indicated facility failure to ensure staff competently administered resident medication. Federal penalty recommended; relevant portions of the complaint report investigation are attached.",3,0,Substantiated,Substantiated,Neglect +TM103916,385244,NF,4/1/2010,Resident #1 was sent to a medical appointment on 04/01/2010 without staff assistance or the required paperwork. Resident #1 had incontinence during the medical appointment; medical staff provided Resident #1 with toileting assistance. The facility failed to provide Resident #1 with incontinence supplies. The facility failed to ensure Resident #1 received care assistance specified in the care plan in place on this date.,2,0,Substantiated,Substantiated,Neglect +OR0000777100,385244,NF,8/8/2012,Evidence and interviews indicated staff #2 (licensed nurse) failed to administer Resident #1's medication by gastric tube and instead administered Resident #1's medication by mouth. This placed Resident #1 at risk for aspiration and resulted in a hospital visit. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +TM120579,385244,NF,7/16/2012,"Evidence and interviews indicated facility failed to provide adequate care for Resident #1. Resident #1 was discharged from the hospital and admitted to the facility on 07/16/2012. Between 2:45 pm and 9 pm, Resident #1 mostly sat in a wheelchair sustaining discomfort. Also, the facility failed to assure Resident #1 received timely and accurate medications.",2,0,Substantiated,Substantiated,Neglect +TM132257,385244,NF,1/17/2013,Evidence and interviews indicated facility failure to protect Resident #1 from rough treatment. The facility's failure to protect Resident #1 from rough treatment resulting in RP2 (care assistant) slapping Resident #1 on the face on 01/17/2013 is considered neglect of care and constitutes abuse.,2,200,Substantiated,Substantiated,Physical Abuse +TM132966,385244,NF,4/11/2013,Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 and Resident #2 resulting Resident#1's behavior escalating. Facility failed to ensure adequate interventions with Resident #1's increased behavior resulting in Resident #1 and Resident #2 engaging in an altercation.,2,,Not Substantiated,Substantiated, +TM134742,385244,NF,9/25/2013,"Evidence and interviews indicated facility failure to provide a safe environment for Resident #1, Resident #2 and Resident #3 resulting in resident-to-resident altercations between Resident #1 and Resident #2 on 09/25/2013 and another resident-to-resident incident between Resident #1 and Resident #3 on 09/26/2013.",2,,Not Substantiated,Substantiated, +TM146691,385244,NF,4/4/2014,Evidence and interviews indicated facility failure to ensure a safe environment with Resident #1 and Resident #2 related to an incident of resident-to-resident contact on 04/04/2014.,2,,Not Substantiated,Substantiated, +OR0000891400,385244,NF,4/18/2014,"Evidence and interviews indicated facility failure to ensure facility staff met professional standards regarding Resident #2's safety related to a fall resulting in Resident #2 sustaining a fractured hip. The Facility failure to ensure Resident #2's safety resulting in Resident #2 sustaining a fractured hip are violations of resident rights, are considered neglect of care and constitutes abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",2,,Substantiated,Substantiated,Neglect +OR0000883700,385244,NF,3/21/2014,"Evidence and interviews indicated facility failure to implement their policies and procedures regarding the investigation and reporting of Resident #1's falls. Facility records indicated Resident #1 sustained falls on 12/22/2013, 1/20/2014, 2/1/2014 and 2/20/2014; according to staff #2 Resident #1 did not sustain injuries as a result of these falls. Evidence and interviews also indicated facility failure to complete neurological checks after Resident #1 sustained a fall bumping her/his head on 12/22/2013, placing Resident #1 at risk of complications from those falls. Evidence and interviews indicated facility failure to follow care planned interventions and ensure Resident #1 and Resident #6's safety placing Resident #1 and Resident #6 at risk for continued falls. Evidence and interviews indicated facility failure to follow care planned interventions for Resident #2 who sustained a fractured left hip. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",3,,Not Substantiated,Substantiated, +OR0000961500,385244,NF,4/7/2015,"Evidence and interviews indicated facility failure to ensure Resident #6 was free from neglect of care during transfer assistance provided by RP2 (CNA) resulting in Resident #6 sustaining a fractured left arm. Evidence and interviews indicated facility failure to ensure Resident #6 received adequate pain management and treatment related to her/his fractured left arm. Evidence and interviews indicated facility failure to report Resident #6's potential injury and new onset of pain to a physician in a timely manner resulting in Resident #6 experiencing a delay in treatment a pain management after she/he sustained a fractured arm. Facility failure to provide Resident #6 adequate care and services related to a fracture arm is violation of resident rights are considered neglect of care and constitutes abuse. Federal penalty recommended, relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +TM153240,385244,NF,10/9/2015,Evidence and interviews indicated facility failure to provide adequate care services for Resident #1 on or about September 2015 when Resident #1 was observed by witness #3 to be wearing the same clothes as two days previous. Witness #3 also found Resident #1 with dried fecal matter on her/him that appeared to be older than two hours. Resident #1's September 2015 care plan indicated she/he should be provided a bedpan as needed and staff were to check for incontinence every two hours and as needed.,2,,Not Substantiated,Substantiated, +OR0000648100,385245,NF,11/16/2010,"Based on interview and record review it was determined the facility failed to implement care planned interventions to prevent Resident #1_x001A_s October 22, 2010 fall. A $1,500 federal civil penalty was recommended. Relevant portions of the survey report are attached.",3,0,Substantiated,Substantiated,Neglect +BH128884,385245,NF,1/5/2012,Evidence and interviews indicated the facility failed to ensure a safe environment for Resident #1 who had a history of elopement attempts.,3,250,Not Substantiated,Substantiated, +BH129419,385245,NF,3/6/2012,"Evidence and interviews indicated facility failure to adequately intervene and redirect Resident #2's inappropriate behaviors toward Resident #1 on March 6, 2012. Resident #2 ran over Resident #1's foot with her/his power chair causing Resident #1 pain.",2,0,Substantiated,Substantiated,Neglect +BH121921,385245,NF,11/27/2012,On 11/27/2012 Resident #1 was erroneously administered 40 mg of a narcotic medication by RP2 (licensed nurse); Resident #1's physician order for the narcotic medication called for 20 mg. Witness #1 indicated the medication order was transcribed onto Resident #1's Medication Administration Record in a way that was confusing. There was no reported indication of a harmful outcome to Resident #1.,2,0,Not Substantiated,Substantiated, +OR0000894100,385245,NF,5/1/2014,"Based on evidence and interviews it was determined the facility staff failed to assess Resident #1 for diarrhea, vomiting, weight loss and narcotic pain medications. Based on evidence and interviews it was determined the facility failed to follow physician_x001A_s orders for the provision of antidiarrheal medications; obtain bone, blood and wound cultures from the local hospital; obtain documentation from the wound care physician_x001A_s examination; assess Resident #1_x001A_s condition before the administration of narcotic medications and adequately assess Resident #1_x001A_s change of condition. Based on evidence and interviews it was determined the facility failed to provide Resident #1 timely nutritional intervention, placing Resident #1 at risk for further weight loss. + +The facility failure to provide Resident #1 adequate care and services related to Resident #1_x001A_s change in medical condition, resulting in Resident #1_x001A_s medical condition developing and/or worsening is a violation of resident rights, considered neglect of care, and constitutes abuse. Relevant portions of the complaint report investigation are attached.",2,1600,Substantiated,Substantiated,Neglect +OR0000874901,385245,NF,1/28/2014,"Based on evidence and interviews it was determined the facility failed to honor Resident #1's right to seek medical attention related to a change in her/his medical condition. Evidence and interviews indicated the facility failure to provide Resident #1 timely medical treatment. + + + +Based on evidence and interviews it was determined facility staff failed to ensure professional standards were followed regarding a thorough assessment of Resident #1's edema, changes in Resident #1's medical condition, ensuring the physician was fully informed of Resident #1's status and failed to provide timely intervention when Resident #1 experienced a change in her/his medical condition. + + + +The facility failure to provide Resident #1 adequate care and services related to Resident #1's change in medical condition, resulting in Resident #1 requiring hospitalization and emergent treatment is a violation of resident rights, considered neglect of care, and constitutes abuse. Federal penalty recommended and relevant portions of the complaint report investigation are attached.",4,2500,Substantiated,Substantiated,Neglect +OR0000946300,385245,NF,1/27/2015,"Evidence and interviews indicated facility failure to ensure professional standards were followed regarding Resident #1's fall on or about 1/27/2015. Staff #2 (CNA) and staff #3 (CNA) failed to report Resident #1's fall to a licensed nurse for assessment of Resident #1's medical condition prior to moving the resident, placing Resident #1 at risk for injury. In addition, evidence and interviews indicated facility failure to ensure that staff #2 (CNA) and staff #3 (CNA) reported Resident #1's 1/27/2015 fall prior to repositioning Resident #1. The facility failure to ensure a licensed nurse assessment of Resident #1's condition prior to staff repositioning Resident #1 placed Resident #1 at risk for injury. Relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +BH153614,385245,NF,2/24/2015,"Evidence and interviews indicated the facility failure to provide Resident #1 adequate, timely medical treatment after Resident #1 sustained a serious burn resulting from spilling hot chocolate on her/himself on or about 2/24/2015. March 4, 2015 progress notes indicated a facility nurse observed Resident #1_x001A_s burned skin areas (2 cm x 7 cm and 2 cm x 9 cm) to have changes with the skin no longer intact. _x001A_Both areas have a brown patch that was dried. Based on observation, areas may have been possible skin damage underneath epidermis; new order for Tylenol 650 TID [three times daily] for [Resident #1_x001A_s pain diagnosis]._x001A_ The facility failure to provide Resident #1 adequate care and services related to Resident #1_x001A_s significant burn, resulting in Resident #1 sustaining prolonged pain and infection to her/his burned skin area is a violation of resident rights, considered neglect of care, and constitutes abuse.",4,2500,Substantiated,Substantiated,Neglect +BH153936,385245,NF,11/21/2015,"Evidence and interviews indicated facility failure to assure Resident #1's safety on or about 11/21/2015 when Resident #1 who was known to be at risk for elopement, left the facility to purchase items at a local store.",2,,Not Substantiated,Substantiated, +BH164355,385245,NF,10/21/2014,"Evidence and interviews indicated facility failure to assure Resident #1's right to be free from verbal abuse by RP2 (licensed physician) on or about 10/21/2014. The facility failure to assure Resident #1's rights, resulting in Resident #1_x001A_s loss of dignity is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +OR0000791700,385250,NF,10/29/2012,"Resident 1 was admitted 9/23/2012 with multiple diagnoses. On 10/17/2012 resident sustained a fall while attempting a self transfer. Staff 9 documented use of a tab alarm and frequent checks which were added to the resident's care plan. The tab alarm was not added to the FYI memo report. On 10/24/2012 resident was found after a fall; no alarm in place. Staff 9 ""thought the alarm had been done, when in fact it had not"" multiple staff failed to note the discrepancy with the temporary care plan. The resident sustained a hip fracture. Relevant portions of the survey are attached. A civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +MS145900,385250,NF,1/11/2014,"The facility incident reports dated 1//3/2014 and 1/16/2014 indicate lost resident personal jewelry. The facility promptly reported to the police, began a thorough investigation and provided resident safety. The facility video captured RP2 entering RV1, RV2, RV3, RV4, RV5 and RV6's rooms. None of the residents were able to give much detail, but W3 and RV5 were able to describe part of the missing items. A police report noted RP2 was cited for Theft, the report was forwarded to the DA and CID. Preponderance of evidence finds RP2 took personal jewelry of RV1, RV2, RV3, RV4, RV5 and RV6; and pawned jewelry for personal financial gain which constitutes financial abuse. Oregon Administrative Rule violation occurred.",3,,Not Substantiated,Substantiated,Financial abuse +MS164195,385250,NF,1/7/2016,Staff left RV momentarily to retrieve gloves. W3 reported returning to find RV with a small skin tear. W3 reported there were no other staff to call to stay with RV at the time of the event. W3 received re-in-service. W3 has no history of disciplinary action. A Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +HB117083,385251,NF,4/30/2011,"Resident #1's was observed to have two rings on her/his finger on 4/23/2011. By 4/30/2011 both rings were missing. A facility internal investigation, law enforcement investigation and this adult protective services investigation failed to provide specific information about a specific perpetrator or the whereabouts of the rings.",2,0,Not Substantiated,Substantiated,Neglect +HB129467B,385251,NF,3/12/2012,Evidence and interviews indicated facility failed to provide Resident #1 adequate toileting and incontinence assistance resulting in Resident #1 sustaining feces on her/his body and bed linens. Resident #1 also sustained at least one instance of waiting for more than 30 minutes to receive toileting assistance.,2,0,Substantiated,Substantiated,Neglect +HB129853,385251,NF,3/2/2012,Evidence and interviews indicated facility failure to provide Resident #1 a safe environment. Resident #1 had a fall from her/his bed on 03/02/2012 sustaining injury and requiring hospitalization.,3,400,Substantiated,Substantiated,Neglect +OR0000773000,385251,NF,7/20/2012,Evidence and interviews indicated the facility failed to respond timely to Resident #2's change of condition. Relevant portions of the survey complaint report are attached.,3,500,Not Substantiated,Substantiated, +OR0000773001,385251,NF,7/20/2012,Evidence and interviews indicated the facility failed to ensure Resident #2 received adequate transfer assistance with a sit-to-stand mechanical lift for transfer resulting in Resident #2 sustaining bruising. Relevant portions of the complaint survey are attached.,2,0,Substantiated,Substantiated,Neglect +HB146358,385251,NF,3/13/2014,"Based on evidence and interviews it was determined the facility failed to ensure a safe environment and adequate care planning related to an incident on 03/10/2014 where facility staff prevented Resident #1 from leaving the facility. The facility failure to ensure Resident #1 a safe environment resulting in Resident #1 sustaining shoulder pain and requiring an x-ray are violations of resident rights, are considered neglect of care and constitutes abuse.",2,250,Substantiated,Substantiated,Neglect +HB147983B,385251,NF,8/1/2014,Evidence and interviews failed to indicate facility failure to provide Resident #1 adequate care and services related to an allegation that Resident #1 did not receive adequate care and treatment services related to Resident #1_x001A_s head and back wound.,0,,Not Substantiated,Substantiated,Neglect +HB152143,385251,NF,7/20/2015,"Evidence and interviews indicated RP2 (CNA) likely refused to provide services on or about 7/20/2015 for Resident #1 while exclaiming she/he would not, ""Help that son of a bitch."" RP2's derogatory language directed at Resident #1 was unprofessional, inconsiderate, and disrespectful. Facility terminated RP2's employment on or about 7/22/2015.",2,,Not Substantiated,Substantiated, +AS117840,385252,NF,7/31/2011,"Neither RV1 or RV2 are oriented per the investigator's interview. RV1 did not remember any incident and RV2 replied ""everything is fine."" W1 reported RP2 went to RV1's room and ""got in RV1's face"" talking of respect for staff. RP2 denied W1 and W2's statements, but did state asked RV1 to be quiet. RP2 reported telling RV2 "" you can't talk to staff like that."" RP2 failed to treat RV1 and RV2 with all due respect given their cognitive state. Evidence is insufficient to support RP2 cussing at RV 1 or RV2.",2,0,Not Substantiated,Substantiated, +OR0000846704,385253,NF,8/19/2013,Staff failed to hold resident Diltazem as ordered placing resident at risk for harm. Relevant portions of the survey are attached. Enforcement action was requested. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000846705,385253,NF,8/19/2013,Five inconsistencies were found resident MAR from 8/20/2013 thru 8/27/2013. staff 9 caught the error and reported to the physician. Staff failed to remove resident Percocet when it was discontinued. Resident was at risk for harm. Relevant portions of the survey are attached. Enforcement action was re4quested. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000846707,385253,NF,8/19/2013,Resident was admitted August 2013 with diagnoses including diabetes and hypertension. Staff failed to recheck and document resident CBG after a reading of 64. staff gave Diltazem when resident blood pressure was outside the parameters resident physician set. There were five instances of MAR inconsistencies from 8/20/2013 thru 8/27/2013. staff gave Percocet due to the Percocet not being removed from the MAR; resident was placed at risk for harm. Staff 9 received further medication and documentation education. Relevant portions of the survey are attached. Enforcement action was requested. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000846701,385253,NF,8/19/2013,Resident was admitted August 2013 with multiple diagnoses including diabetes. Staff 6 failed to recheck resident CBG when CBG was 64. staff received further education. Relevant survey pages are attached. Enforcement action was requested. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +BO152419,385253,NF,7/25/2015,"Due to a facility system failure RV did not receive his/her food tray timely after RV had received his/her pre-meal insulin injection resulting in RV developing severe hypoglycemia. RV required transport to the ER and hospitalization. Multiple staff delivered food trays to the residents on RV's floor, but RV did not receive a tray and staff were not aware of this fact. Staff in the dining room found RV's tray on the dining room cart, but were unable to timely communicate with floor staff (staff radios were not functioning) to ascertain whether or not RV was coming to the dining room or RV's tray required delivery to RV's room. The facility's poor system for delivery of food trays and failure to maintain adequate communication devices resulting in RV sustaining severe hypoglycemia constitutes abuse by neglect. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +NB116965,385254,NF,5/8/2011,"RV1 reported RP2 ""yelled"" at RV1 and felt like RP2 picked on him/her. RV2 reported RP2 yelled at residents and told RV2 to walk downstairs or would not get a meal; RV2 reported being ""very upset."" RV3 reported RP2 told RV3 had to walk to dinner or would not get to eat, took food from resident's rooms and would not allow residents to smoke. RV4 reported RP2 refused to give RV4 milk one time and told RV4 ""if you don't go downstairs you don't eat."" RP2 failed to treat residents with respect, dignity and or allow residents their choice in care; to smoke or not. Residents complained of being upset. The facility suspended and terminated RP2's employment.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +NB118614,385254,NF,12/2/2011,"Witnesses acknowledge an out break of scabies in residents in 2010. Witnesses reported all residents and their furnishings were treated. W5 reported management provided cream for staff, too. W4 and 5 reported there are residents now (12/6/11) with some rashes, dry skin, etc., but no known scabies. On 12/6/11 W7 and 8 reported no staff had reported signs or symptoms of scabies. On 12/8/11 and in-service was presented to staff regarding CDC information on scabies. On 12/28/11 W7 reported RV2 and RV3 were treated with oral medication for scabies. Staff should have received in-service or information at the earlier outbreak.",2,0,Not Substantiated,Substantiated, +OR0000790500,385254,NF,10/22/2012,"Resident 1 was admitted with multiple diagnoses in 20122. the 6/12/2012 in room care plan indicated a sit to stand lift. Resident safety concerns included fall risk due to multiple factors. The 9/25/2011 comprehensive care plan included a sit to stand or Hoyer lift. The resident in room care plan of 9/25/2012 showed transfer by Hoyer or sit to stand. The resident was able to make his/her needs known. Nursing notes of 10/19/2012 indicated the resident doing well with stand pivot transfers to help strengthen his/her legs. The nursing notes indicated using two people for the transfer. The resident in room care plan did not reflect use of two people for all transfers. Staff 5 reported the sit to stand was broken, no other staff were available to help, the resident did not want to wait and when staff transferred the resident they heard a Pop. The resident let go of staff's neck and staff and resident both lost balance. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +NB146133A,385254,NF,2/19/2014,"On or about February 18, 2014 RP2 failed to stop and re-approach, attempt to redirect and or allow RV choice in his/her care. RP2's and RV's interaction resulted in raised voices, RV sustaining a skin tear to his/her right hand area and bruises. RP2 failed to treat RV with respect and dignity; and provided rough care resulting in injury to RV. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Physical Abuse +NB146133B,385254,NF,2/19/2014,"On or about February 18, 2014 RP2 failed to stop and re-approach, attempt to redirect and or allow RV choice in his/her care. RP2 told RV he/she had to get up and get dressed despite RV stating ""no"". Witnesses describe RP2 as ""abrupt""', ""grumpy"" and ""mean"". RP2 admitted telling RV if (another resident) had to get up then so do you. RP2 stated RV did say ""no"" and RV pushed self back. RP2 failed to treat RV with respect and did ""harass"" RV. Licensed staff knew of RP2's behaviors of gruffness and poor communication with residents. The facility failed to appropriately address RP2's behaviors allowing the interaction between RV and RP2 to escalate. The interaction resulted in emotional and verbal abuse of RV. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Verbal/Mental abuse +OR0000986100,385254,NF,7/31/2015,"Staff 5 reported Staff 13 failed to provide incontinence care for Resident 1, 6, 7 and 8 as Staff 13 reported prior to taking a break. Staff 13 acknowledged failure to provide care to an unknown number of residents. Residents were at risk for worsening skin issues. Staff failed to document care provided. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000986101,385254,NF,7/31/2015,On 7/13/2015 staff discovered an open area near the base of resident's spine. The ulcer was unavoidable. Additional sample residents indicate Resident 2 acquired a Stage II pressure ulcer and it became a Stage III. The facility failure constitutes abuse. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +OR0000986102,385254,NF,7/31/2015,"Resident 1, 2 and 4 sustained falls without adequate assessment and interventions adopted. Resident care plans were not updated following falls resulting in further falls with injury. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0001019300,385254,NF,10/22/2015,"Resident 4 was admitted June 2015 with diagnoses including dementia. Resident MDS of 6/21/2015 indicated the resident required two person transfer and one staff for wheel chair locomotion. The resident's CAA revealed a history of falls and instability when standing from a seated position. Interview and record review indicated between the 6/10/2015 assessment an assessment form of 9/28/2015 the resident had not fallen when in fact the resident had fallen a number of times without an up date on the in room care plan. The resident fell on 10/21/2015 and sustained a head injury. Witness interview noted some new interventions, but the in room care plan did not provide direction to care givers. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +NB164811,385254,NF,3/1/2016,"The facility failed to have adequate medication systems in place to ensure RV1, RV2, RV3, and RV4's narcotic medication was safe from theft. The facility failed to ensure RV1, RV2, RV3 and RV4's medical record accurately identified when narcotic medication was given and the response there too resulting in potential physical harm. Evidence noted in the investigation report supports theft of RV1's medication on at least two separate occasions; and discrepancy as to whether or not RV2, RV3 and RV4 required and or received narcotic medication when RP2 was dispensing medication. RV1 kept a written record of when RV requested and received narcotic medication. Record review and staff interview indicate RP2 signed out narcotic medication for RV2, RV3 and RV4, but did not deliver the medication to the RVs and or failed to properly document dispensing of the medication. RP2's actions constitute financial exploitation. The facility knew of medication discrepancy in December 2015, but failed to take adequate precautions to prevent the on going theft of resident medication. Oregon administrative Rule violations occurred.",3,1200,Substantiated,Substantiated,Financial abuse +DL117732,385257,NF,8/11/2011,"The facility failed to ensure a safe environment resulting in theft of RV1's phone charger, grinder, socks, money and two lighters on or about 8/9 or 8/10/11. RV1's phone charger was returned by an unknown person or persons on 8/12/11. RV2 reported missing money to W1 approximately ""a few weeks prior to 8/18/11"", but W1 failed to report the theft. W1 reported RV2 was ""pretty out of it"" at the time. Staff failed to promptly report all alleged thefts to law enforcement or SPD.",2,300,Substantiated,Substantiated,Financial abuse +DL117969,385257,NF,8/13/2011,"RV reported having a place to lock valuables, but he/she had the watch in the night stand. W1 reported last seeing RV's watch on August 6, 2011 and it was gone on August 13, 2011. W2 reported police and crime stoppers were notified. On 9/19/11 W3 reported the watch was found and now family has the watch. The watch had been misplaced instead of stolen.",2,0,Not Substantiated,Substantiated, +DL117730,385257,NF,8/10/2011,"RP2 and RV give conflicting reports as to RP2 transferring RV on 8/10/11. RV did state RP2 had been rough ""months"" before. RP2 stated RV was in pain and reported this, but there is lack of documentation neither confirms or denies the event. Given the evidence presented a reasonable person could neither confirm or deny rough care occurred. Since RV stated a former event occurred and poor documentation occurred, the facility failed to ensure a safe environment for RV.",2,0,Not Substantiated,Substantiated, +DL118259,385257,NF,10/18/2011,RV sustained loss of personal items. The facility has cooperated with LEA and initiated other intervetnions including Crime Stoppers. W6 reported items will be replaced.,2,0,Substantiated,Substantiated,Financial abuse +DL118693,385257,NF,12/10/2011,"RV has missing items and the facility will reimburse RV for the items. RV has a locking drawer in his/her room, but chooses not to use it. RV also has a safe in his/her room, but does not always lock it. W1, 2 and 3 reported observing the missing items. W4 reported RV had given him/her a DV/VHS player as RV thought it was broken. W4 reported RV would not take no for an answer. W4's employment was terminated; staff are not to accept gifts from residents. The facility is working with the police, crime stoppers and encouraging residents to lock up their valuables.",2,0,Substantiated,Substantiated,Financial abuse +DL129084,385257,NF,1/26/2012,"RV, W1 and RP2 agree RP2 said may have used the F word. There was no evidence by RV during the investigation interview with RV that RP2 used the F word towards RV. RP2 voiced frustration in assisting RV with special stockings. RV was not treated with all due respect. The facility will provide further staff in-service. The failure represents a violation of resident rights and a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated, +DL128942,385257,NF,1/15/2012,"RV1 and RV2 reported theft of personal items. Both RVs do not believe the items were taken by staff. The facility reimbursed the RVs, alerted crime stoppers and law enforcement. The facility constitutes abuse and a Oregon Administrative Rule violation.",2,0,Substantiated,Substantiated,Financial abuse +DL129474,385257,NF,3/8/2012,"RV reported RP2 stated there wasn't any ice cream when RV requested ice cream. RV also reported RP2 yelled and argued with RV when RV confronted RP2. RV denies any other issues. W1 reported observing RP2's interaction with residents and RP2 can be argumentative. W2 counseled RP2 previously regarding RP2's tone of voice appearing ""short"". RP2 reported his/her voice can be loud. RP2 apologized to RV. RP2 reported not being aware that Ice cream was kept in a pantry on the wing. RP2 failed to treat RV with all due respect and honor RV's request for ice cream. The incident represents a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +DL120093,385257,NF,5/7/2012,"W2 and W5 observed RP2 tell RV that RV could not go in the gazebo to smoke. W2 and W5 observed RV tell RP2 that it was hot outside and RV wanted to sit in the gazebo. RV recall the event, but not the care giver name. RP2 reported it was hot day, the gazebo gets hot inside and RP2 suggested they sit outside. RP2 reported RV did not ask more than once and RP2 did not recall RV getting upset. RP2 denies RV finished the cigarette early. RP2 failed to honor RV's choice. The facility placed RP2 on a specific work plan with active monitoring. Evidence does not support any emotional upset for RV due to this isolated event. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +DL120297,385257,NF,6/13/2012,"RV retrieved $100.00 from his/her trust account on 6/12/2012, gave $40.00 to a child and left $60.00 in his/her wallet. RV left the wallet unsecured in his/her night stand over night and discovered the money missing in the morning. The faculty took prompt action notifying LEA, crime stoppers, SPD, et. RV denies any prior missing items. RV reported attempting to use the locking drawer, but was unable due to his/her sight. The facility is in the process of obtaining different drawers. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +DL120449,385257,NF,7/6/2012,RV reported missing money from his/her wallet in the last 30 days and was reimbursed. RV now reported missing quarters left unsecured in a pill bottle. New lock boxes are being given to residents as the present locking box drawer are difficult to open and lock. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +DL120660,385257,NF,7/23/2012,"On or about July 23, 2012, RV1 (Resident #1) and other OVA residents at Oregon Veterans Home, reported theft of RV1's camera and other missing resident items. W1 reported the locking drawer lock is not secure and there is truly no safe place to keep things. W2 (staff) observed RV1's camera on a shelf in W1""s room, reportedly got side tracked and did not ensure the camera was returned to RV1 before it went missing. W2 also reported RV1 has trouble using the key for the locking drawer. RV1 reported the facility did not offer to pay for or replace the camera. RV1 reported other missing items over the year and states he/she now keeps everything locked up. Facility staff was remiss in not taking RV1's camera to RV1 or ensure safe placement of the camera. RP2 admitted to police to taking pop, small change (coins) from RV1 and other resident's items, but denies taking the camera. RP2's theft of RV1 and resident's items constitutes abuse. Facility repeated failure to keep RV1's and other residents' belongings safe constitutes abuse. Facility failure is an Oregon Administrative Rule violation.",2,200,Substantiated,Substantiated,Financial abuse +DL121248,385257,NF,9/10/2012,"RP2 failed to follow RV's care plan regarding fluids. RP2 gave RV thick liquids and left thick liquids at the bedside after RV stated he/she could have water or thin liquids. RP2 failed to check and ensure what liquids RV could consume and failed to honor RV's request. RP2 turned RV quickly causing RV some discomfort, but evidence is inconclusive RP2 was rough with RV's care. An Oregon Administrative Rule was violated.",2,0,Not Substantiated,Substantiated, +DL118396,385257,NF,11/4/2011,"RP2 admitted taking money from multiple residents including RV4, 5, 6, 7, and 8. RP3 admitted taking money from residents including $10.00 from RV5. RP2 and RP3's theft of money from resident (s) constitutes financial abuse. The facility knew of thefts of money from residents, but failed to stop the thefts in a timey manner which constitutes abuse. The facility did assist in a ""sting"" operation with the police and reported thefts to APS. The facility immediately terminated RP2 and RP3's employment and reported them to OSBN once RP2 and RP3 were found to have taken resident's money.",2,0,Substantiated,Substantiated,Financial abuse +DL132801,385257,NF,3/27/2013,RV's money went missing from his/her wallet. RV's spouse will be depositing money to RV's trust account. RV reported losing the key to the locking drawer and kept the money in his/her wallet in his/her jacket. The facility reported the theft and will be placing surveillance cameras. An Oregon Administrative Rule violation occurred.,2,0,Substantiated,Substantiated,Financial abuse +DL133202,385257,NF,5/3/2013,"RV reported loss of money and gift card and police were alerted. RV was aware he/she could have placed valuables in a locking drawer. The facility is looking into reimbursing RV, as well as, placing surveillance cameras in the facility. Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Financial abuse +DL132181,385257,NF,1/16/2013,Staff are aware RV has coins in his/her room and RV has been a victim of theft in the past. RV refuses to use lockable space to store the coins. The facility reported the theft to police and APS. The facility failed to protect RV from theft. The facility will be installing cameras to help decrease the chance of thefts. An Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Financial abuse +DL133899,385257,NF,6/21/2013,"RP2 accepted money from RV despite knowing and understanding facility policy not to accept money/gifts from residents. RP2 took a check of RV's, forged RV's signature and cashed the check for $1,200.00. RP2 admitted taking and forging RV's check, as well as, accepting other money from RV. The facility took immediate action to protect RV and other residents when notified of a discrepancy in RV's bank accounts. RV received reimbursement as this reviewer clarified with the facility administrator. An Oregon Administrative Rule violation occurred.",3,,Not Substantiated,Substantiated,Financial abuse +DL134698,385257,NF,9/14/2013,"RV1 and RV2 are unable to provide relevant information. The complainant reported this is a second event for RV1 and RV2. RV1's medication has been adjusted. RV1 had anger and aggressive issues. W2 observed RV1 go to RV2, exchange words and strike RV2. RV1 and RV2's care plan was not changed until 9/19/2013 after the second event occurred. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +DL146911,385257,NF,4/23/2014,"RV has limited use of his/he hands, carries money in shirt pocket and staff assist RV in placing the money in shirt pocket or night stand. RV's money went missing between 4/23 and 4/25/2014. W1 reported roommate as possible suspect. W1 reported roommate had a $10.00 dollar bill with the new pinkish tone like the one RV had. RV lost his/her cell phone at the time the money went missing. RV's cell phone was found in the laundry. Staff were advised to carefully check RV's pocket before sending clothes to the laundry. The facility will reimburse RV's money. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +DL148642,385257,NF,9/13/2014,"RV refused to have his/her bedding changed; bedding changed approximately one hour earlier. W1 and RV reported RP2 ""yelled"" at RV ""to quit acting like a child"". RP2 told RV ""I will knock your lights out and call the police"" in response to RV telling RP2 ""if you touch me I am gonna hit you"". RV reported being in a lot of pain, waiting for medication and requesting to be left alone. RP2's behavior/actions constitute mental abuse and a failure to honor RV's choice of care. While W1 immediately reported the event to licensed staff, RP2 continued to provide care to RV during RP2's shift. The facility failed to provide immediate intervention to protect RV and other residents from suspected abuse during the time RP2 was allowed to work. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +OR0000907500,385257,NF,7/9/2014,"Resident 1 was admitted 6/2013 with multiple diagnoses including quadriplegia. Resident's MDS dated 6/19/2014 identified one person assist with transfers, limited ROM and wheel chair use for mobility. Resident care plan identified fall risk with interventions listed. On 7/8/2014 at 12:03 A.M. Staff 3 assisted the resident to bed using a lift; the resident began to slide off the bed edge and was assisted to the ground. Resident was sent for evaluation and x-rays which were negative for shoulder fracture. Resident's right ankle sowed a probable fracture. The resident follow-up x-ray found no fracture. Resident's care plan had been changed to two person transfer just before Staff 3 assisted the resident. Staff 3 failed to follow the care plan and the facility culture was to use a one person transfer. Staff 3 reported asking for other staff assistance, but other staff were busy. The staffing report confirms staffing was below minimum at the time of the incident. The facility failed to ensure staff followed resident care plans. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +DL149709,385257,NF,12/16/2014,"RV reported keeping billfold in his/her shirt pocket, keeps shirt on while sleeping, changes shirt daily and found money missing in the A.M. when changing the shirt. RV reported usually kept $400.00 to $500.00 at a time, but will discontinue this practice. W4 reported a police investigation continues. RV's monies will be reimbursed. The facility is laying cable for a new call light and security system. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +DL149558,385257,NF,12/10/2014,"RV1, RV2, RV3, RV4, RV5 and RV6 had personal possessions including wallets, money and or boots go missing within a few weeks period of time in December 2014 as identified in the attached investigation report. RV1, RV2 and RV3 reported they were not given keys or knew of keys for their locking drawer. RV5 reported his/her wallet containing money and the shorts the wallet was placed in went missing overnight. RV6 reported his/her boots went missing from his/her bedroom during the night time. RV6 reported ""feeling bad""when finding the boots were gone. While 4 of the 5 wallets were found on top of various Resident closets, money and identification was not retrieved. The facility failed to ensure a safe environment resulting in theft of resident possessions and money. The facility's repeated failure to keep RV1, RV2, RV3, RV4, RV5 and RV6's belongings safe constitutes abuse. Oregon Administrative Rule violations occurred.",3,500,Substantiated,Substantiated,Financial abuse +DL151719,385257,NF,6/21/2015,"The complainant and W1 voiced multiple concerns regarding RV's care and services as indicated in the investigation report. The concerns included poor incontinence care; failure to assist RV with eating, monitoring and providing meal replacements; failure to adequately monitor RV's weight and or address RV's weight loss; failure to notify family of all care conferences; failure to properly notify family of RV's falls; and failure to provide adequate housekeeping of RV's room and care equipment resulting in odors and an infection control risk. RV was unable to provide relevant information due to RV's cognitive impairment. Witness interview and resident record review provides evidence to support housekeeping issues and odors; facility failure to care plan RV's need for assistance with eating, adequate meal monitoring and ensure meal replacements were offered; facility failure to adequately monitor and or provide incontinence care and or hygiene resulting in RV being left with dried feces on RV's body and hands; and facility failure to adequately care plan and/or monitor RV's weight including RV's weight loss. The facility did invite family to care conferences. Based on further information provided, a facility team meeting is not a care conference, but a team discussion regarding what the team would like to be able to implement with the family being apprized of what the team would like to implement. The facility failure to provide adequate care and services resulted in RV's loss of dignity, , undesirable weight loss and great potential for skin breakdown. The facility neglect of care constitutes abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +DL152208,385257,NF,6/21/2015,"The facility failed to provide a secure environment resulting in loss of RV's ring on or about June 21, 2015. RP2 was convicted of Criminal Mistreatment in the First Degree, Felony Class C committed on or about 7/22/2015. RP2 sold RV's ring to a jeweler for personal gain; received $75.00 in the form of a check. RP2's actions constitute abuse by theft. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Financial abuse +DL121260,385257,NF,9/28/2012,"RV1, RV2, RV3 and RV4 all reported missing monies; some money was left in unlocked drawers or the key to the locking drawer was unavailable. The facility failed to provide a safe environment resulting in theft of resident monies. The 2012 investigation report was not turned in timely for review until 12/9/2015. Due to the report being over three years old a monetary sanction will not be levied. Since these thefts occurred, the facility has installed cameras in the hallway. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Financial abuse +AL153841,385257,NF,11/3/2015,"RV reported having $172.00 in his/her wallet the night of 9/23/215 and checking the wallet on 9/27/2015 to find only $72.00. RV reported five $20.00 bills were missing. RV reported multiple staff had been in and out of RV's room; no visitors. RV did not have a key for his/her drawer, but received one after this event. Staff replaced RV's missing money. The facility failed to have a safe environment resulting in the theft of r's money. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +OR0000662800,385258,NF,1/21/2011,Evidence and interviews indicated facility failure to complete timely investigations of Resident #1's unwitnessed falls and bruises of unknown injury. Relevant portions of survey report are attached.,2,500,Substantiated,Substantiated,Neglect +OR0000662801,385258,NF,1/21/2011,Evidence and interview indicated facility failure to provide Resident #1 the necessary care and services related to a change in condition. Relevant portions of the survey report are attached.,2,0,Substantiated,Substantiated,Neglect +BC116685,385258,NF,4/4/2011,"On 4/4/2011 RP2 (CNA) was heard telling Resident #1 _x001A_you can make this hard or you can make it easy. If you don_x001A_t cooperate with me, you can just lay in your urine all night._x001A_",2,0,Not Substantiated,Substantiated, +BC117299,385258,NF,6/17/2011,Evidence and interviews indicate facility failed to provide Resident #1 therapeutic meals as ordered.,3,250,Not Substantiated,Substantiated, +BC117850,385258,NF,8/25/2011,"Resident #1 said on 8/25/2011 RP2 (CNA) asked Resident #1 to stop yelling. Resident #1 said she/he was not yelling and RP2 said 'as a black person' you might just be talking, I don't know.' Resident #1 was upset by the comments RP2 directed at Resident #1 on 8/25/2011.",2,0,Not Substantiated,Substantiated, +BC118704,385258,NF,10/11/2011,"Evidence and interviews indicated facility failed to maintain a safe medication system. Resident #1 was administered her/his once every seven day medication on three consecutive days, staff resumed administering the medication eight days later. RP2 (licensed nurse) erroneously administered Resident #1, Resident #2's am medication on 10/14/2011 and RP2 erroneously administered Resident #2, Resident #1's am medication on 10/14/2011.",3,200,Not Substantiated,Substantiated, +BC129457,385258,NF,3/7/2012,"Evidence and interviews indicated RP2 (CNA) ""mistakenly"" transferred Resident #1 from her/his bed to her/his chair without additional help on 03/07/2012. RP2 said she/he had never worked with Resident #1 prior to 03/07/2012 and that a (2) looked like a (1) on Resident #1's care plan.",2,0,Not Substantiated,Substantiated, +OR0000763400,385258,NF,5/24/2012,Evidence and interviews indicated facility failure to provide adequate care and services related to resident falls resulting in Resident #1 and Resident #2 sustaining falls with injuries. Relevant portions of the complaint report are attached.,2,500,Substantiated,Substantiated,Neglect +OR0000770000,385258,NF,6/29/2012,Evidence and interviews indicated the facility failed to provide adequate care and services regarding Resident #1_x001A_s 06/26/2012 fall with injury. Relevant portions of the survey complaint report investigation are attached.,2,300,Substantiated,Substantiated,Neglect +BC120694,385258,NF,7/18/2012,Evidence and interviews indicated facility failure to maintain an adequate medication administration system resulting in RP2 (licensed nurse) making multiple medication administration errors and the potential for serious harm to residents.,3,250,Not Substantiated,Substantiated, +OR0000824400,385258,NF,4/18/2013,"Evidence and interviews indicated facility failure to ensure Resident #1 received adequate supervision and assistance to prevent a fall. Resident #1 sustained a non-witnessed, non-injury fall on 04/16/2013. Relevant portions of the complaint report investigation are attached.",2,0,Not Substantiated,Substantiated, +BC147387,385258,NF,6/9/2014,"Evidence and interviews indicated RP2 took Resident #1's debit card to purchase cigarettes for Resident #1 on 06/08/2014. RP2 said that she/he used Resident #1's debit card to withdraw money and purchase cigarettes for Resident #1. Resident #1 said RP2 did not return any cash nor debit card to Resident #1 on 6/8/2014. The amount Resident #1 said that RP2 failed to provide her/him after taking it from Resident #1's banking account was in excess of $300.00. These failures are considered a violation of resident rights, considered financial exploitation and constitute abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BC148732,385258,NF,9/26/2014,"Evidence and interviews indicated facility failure to protect Resident #1 from rough treatment. Resident #1 said she/he was lying in bed on 9/26/2014 when a CNA _x001A_grabbed_x001A_ Resident #1 by the wrists and lifted Resident #1 to a sitting position. Resident #1 said she/he told the staff assisting her that they were _x001A_hurting_x001A_ Resident #1 at the time. Evidence and interviews indicated Resident #1 was observed to have bilateral bruising that were caused from finger marks and _x001A_consistent with someone grabbing_x001A_ Resident #1 to lift her/him out of bed. The Facility failure to protect Resident #1 from rough treatment while receiving care assistance resulting in Resident #1 sustaining bruising are violations of resident rights, are considered neglect of care and constitutes abuse.",2,200,Substantiated,Substantiated,Neglect +OR0000978400,385258,NF,6/30/2015,"Evidence and interviews indicated facility failure to adequately assess the risk or provide adequate interventions to minimize falls or injury related to Resident #35's preference for an elevated bed, placing Resident #35 at increased risk for falls and injuries. Relevant portions of the complaint report are attached.",2,,Not Substantiated,Substantiated, +OR0000978401,385258,NF,6/30/2015,Evidence and interviews indicated facility failure to adequately assess and notify the physician of an acute change in condition for Resident #25. This failure placed Resident #25 at risk for medical needs not being met. Relevant portions of the complaint report are attached.,2,,Not Substantiated,Substantiated, +OR0000986200,385258,NF,8/3/2015,"Evidence and interviews indicated facility failure to follow physician orders for the administration of Resident #1's medication. Resident #1 was administered incorrect medications by a student nurse on 7/31/2015. Emergency services transported Resident #1 to the hospital for treatment and monitoring. The facility failure to administer Resident #1_x001A_s medication as ordered resulting in Resident #1 requiring hospitalization are violations of resident rights, are considered neglect of care and constitute abuse. Federal penalty recommended relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +BC164739,385258,NF,2/16/2016,"Evidence and interviews indicated facility staff failed to provide Resident #1 with timely assistance with hygiene on or about 2/16/2016. Evidence and interviews indicated facility staff were aware Resident #1 needed hygiene assistance for approximately an hour or more; leaving Resident #1 in urine in feces on a floor mat next to her/his bed. The facility failure to provide Resident #1 timely assistance with hygiene, resulting in Resident #1 laying in urine and feces for approximately an hour, is a violation of resident rights, considered neglect of care, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +OR0000650103,385259,NF,11/29/2010,Staff reported licensed nurses do answer calls outside the SNF/NF leaving no licensed nurse for the SNF/NF. The facility failed to ensure a licensed nurse was on duty every night who was not required to respond to residents outside the SNF/NF. The facility has changed their policy regarding nurse response to areas outside the SNF/NF. Relevant portions of the survey are attached.,0,0,Not Substantiated,Substantiated, +OR0000854700,385259,NF,9/27/2013,Resident 1 was admitted 9/2013 with diagnoses including epilepsy. Resident's physician orders dated 9/19/2013 indicated Dilantin 100 mg three tabs were to be given. The resident did not receive the ordered medication. The resident was at risk for harm. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +BC147147,385259,NF,5/16/2014,"Staff including RP2 and RP3 believed RV was out of the building with either W10 or W4. Staff failed to physically check RV's location or actually check RV's wander guard at 4:00 P.M. RV was observed at approximately 1:00 P.M. in the dining room, but staff failed to realize RV was missing until approximately 9:00 P.M. Police returned RV at approximately 9:30 P.M., after finding RV two miles away in a park. While RV did not sustain injury during the approximate seven plus hour elopement, RV was at a great risk for harm. RV's great risk for harm constitutes abuse by neglect. Oregon Administrative Rule violations occurred.",3,200,Substantiated,Substantiated,Neglect +BC154082,385259,NF,12/27/2015,"On 12/27/2015 RV was assisted to the toilet as care planned with the use of one person. RV was assessed as alert and oriented. RP2 stayed in RV's room for approximately 10 minutes when RV told RP2 that RV is slow having a bowel movement. RP2 ensured RV had the call light, instructed RV to use the call light when RV was finished and left the room at 9:47 A.M. as the hallway camera indicated. RP2 was covering the floor as W4 was on break beginning about 9:45 A.M. RP2 went on break at approximately 10:31 and reported telling W4 RP2 was going on break, but ""forgot"" tell W4 that RV was on the toilet. RV put on the call light at 10:10 A.M. and was found on the floor at 10:55 A.M. RV's hall call light is not easily visible for staff ""simply"" glancing down the hallway; it is obscured by an emergency light. Staff report non working pagers and insufficient amounts of pagers for all staff to have a pager when working. The facility failed to ensure sufficient pagers for staff to receive call light information, the facility failed to have adequate visibility of a call light and failed to have all staff respond promptly to all initiated call lights. RV's fall and fracture were preventable which constitutes abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +BH105665A,385260,NF,11/8/2010,"RV1 reported RP2 made RV1 wait until the next shift for care; RV1 became frustrated with care and crying. RV2 reported becoming incontinent and RP2 ""scolded"" RV2. RV2 also reported RP2 telling RV2 to ""hold it"" when requesting assistance to the bathroom. RV3 was unable to provide relevant information regarding RP2's care. W3 reported RP2 telling RV3 to wait for assistance until the next shift. W3 reported concerns to the nurse. RP2 failed to provide necessary care and services to RV1, RV2 and RV3 while forcing them to wait for toileting assistance or linen change. RP2 failed to treat RVs with respect and dignity.",2,0,Substantiated,Substantiated,Neglect +BH105665B,385260,NF,11/8/2010,"RV1 reported RP2 continued to remove RV's arm sling in a rough manner causing RV1 pain even after RV1 told RP2 of the pain. RV1 denied physical injury, but stated he/she ""cried in frustration"". RP2 failed to honor RV1' choice of care causing continued pain.",2,0,Substantiated,Substantiated,Neglect +BH118553,385260,NF,11/21/2011,"RV receives medication that can increase bruising. RP2 assisted RV to the toilet and RV sat down ""hard"" per RV1. RV1 stated the toilet was too low. RP2 was not he assigned aide for RV1, was trying to help other staff and did transfer by him/herself. RP2 reported RV helped quiet a bit, did not notice any problems and denied RV saying anything. Evidence is inconclusive who or what may have caused RV's bruising. RV's care plan was adjusted for further safety and use of a bedside commode. All staff received further in-service.",2,0,Not Substantiated,Substantiated, +OR0000923200,385260,NF,9/23/2014,Resident 1 was admitted 07/2014 with multiple diagnoses including rheumatoid arthritis. Resident's physician orders included prednisone with specific dosage and parameters for administration. The facility failed to give medication as ordered. The resident sustained a change of condition and was hospitalized. Relevant pages of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +BH165032A,385260,NF,9/25/2015,"W3 stated RV was re-admitted from the hospital on 8/10/2015 with written dietary instructions, staffed RV's diet as a training , change liquids from honey thick to nectar thick and failed to change the order back. W8 reported it was four days before the change to the correct liquids occurred. W8 also said there was a sign at RV's bedside regarding liquids; W5 corroborated W8's statements. RV was placed at risk for harm. Oregon Administrative rule violations occurred. .",2,,Not Substantiated,Substantiated, +BH165032B,385260,NF,9/25/2015,W5 reported RV was given Coreg and RV was allergic to this medication. W5 believed RV's health decline was due to RV receiving Coreg. RV's hospital discharge did not list Coreg as an allergy. RV received Carvedilol a generic form of Coreg although RV was reportedly allergic to Coreg. RV received 10 doses of Coreg (Carvedilol) before it was discontinued on 8/15/2015. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +RD106009,385261,NF,12/21/2010,"RV and RP2 have been ""friend"" for years. RP2 placed a decoration on RV's privates parts as a joke. RV was upset because RP2 told other staff about the incident. Both RV and RP2 reported the event was not sexual in content. RP2 used extremely poor judgment in his/her actions. RV was not given all due respect. The facility terminated RP2's employment and notified the Oregon Board of Nursing.",2,0,Not Substantiated,Substantiated, +OR0000671300,385261,NF,2/25/2011,Resident 2 was admitted November 2007 with multiple diagnoses and a history of falls. Resident 2's care plan of January 2011 directed staff to use a tab alarm at all times and one staff to use a gait belt while assisting Resident 1 with ambulation. Staff found Resident in the hallway on 2/11/11 having ambulated independently. Staff 1 reported Resident 1 had been ambulating independently prior to his/her fall and the CNA care plan was unavailable. The facility failed to follow Resident 1's care plan resulting in Resident 2's fall and fracture. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +RD129296A,385261,NF,1/5/2012,"Staff failed to provide a calm atmosphere when ""slamming down"" a urinal. RV was not afforded all due respect. Evidence does not provide sufficient evidence to support inappropriate verbal comments. Evidence remains inconclusive regarding an written incident report. The facility failure represents a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +RD129296B,385261,NF,1/5/2012,"A 2/21/2012 telephone call tevealed W1 just receiving report of 1/12/2012 incident in which RP3's actions contributed to escaltion of RV's behaviors. W1 reported RV's behavior escalated to the point police were called. RP3 denied grabbing or yelling at RV. RV is unable to be interviewed. Multiple witnesses deny RP3 ""grabbed"" RV, but witnesses did state RP3 ""yelled"" for staff to call 911. RP3 was in a tug of war with RV over a stick RV ws holding. RV's care plan to use a gentle relaxed tone was not consistently applied. The facility failure represents a Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +RD148477,385261,NF,9/8/2014,"RV stated ""yes"" when the investigator asked if RV was treated roughly and if someone ""slapped"" RV's hand. W3 reported being in RV's room with RP2, rolling RV toward RP2 while telling RV to grab the side rail, observing RP2 ""grab"" RV's wrist, yank RV toward the rail, ""slam"" it on the bar and ""slap"" RV's hand while telling RV that RV needed to ""fucking"" help us. Initially on 9/15/2014 RP2 denied using the ""f"" word and denied grabbing or slamming RV's hand on the rail. RP2 telephoned the investigator on 9/24/2014 and reported using cuss words around RV. Further evidence through personal informal conference interview with RP2 finds insufficient evidence to support physical and verbal abuse. The facility took prompt and appropriate action to provide a safe environment for RV. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +WB116816,385262,NF,4/20/2011,"RP2 failed to treat RV with all due respect; ""loudly told RV not to get up"" while leaning close to RV with RP2's hands on either side of RV's shoulders. RV denies improper treatment, but RV has dementia. RV was not observed to be upset.",2,0,Not Substantiated,Substantiated, +WB121791,385262,NF,11/29/2012,"RV receives blood thinner. RV developed a large bruise to the left lower arm. RV reported it hurt and that she/he did tell staff, but staff audit did not show the bruise. Staff discovered the bruise on 12/2012, but failed to immediately notify RV's physician. RV was examined on 12/4/2012 and required immediate vitamin K due to high blood levels of medication which thins RV's blood. RV did not receive timely medical treatment placing RV at risk for further harm. An Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Neglect +WB147756,385262,NF,7/5/2014,Staff failed to provide transfer to the wheel chair as care planned. RV could still have sustained the skin tears to the lower leg/foot during a two person transfer as the portion of the wheel chair where the foot pedals attached were not padded allowing RV or any resident with fragile skin to come in contact with a sharper metal edge. The facility failed to ensure a safe environment resulting in RV sustaining skin tears. Staff received further instruction to follow care plans and RV's wheel chair exposed metal edges were padded. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0000976100,385262,NF,6/16/2015,"Resident 55 was admitted 6/6/2015 with diagnoses including Parkinson and physician ordered medication for Parkinson. On 6/7/2015 the physician discontinued Comtan, but according to the MAR the resident continued to receive the medication between 6/8 and 6/15/2015 without noted effect. Additional review of another resident indicated Resident 1 received an antidepressant without attempt to gradually reduce the dosage. The resident was placed at risk for unnecessary medication. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000662900,385263,NF,1/21/2011,"Staff applied a TAB alarm instead of a pressure alarm when RV was in bed. RV fell from bed and sustained a facial injury. RV received Tylenol for complaint of a headache. Alarms in and of themselves will not prevent sudden falls, but will immediately alert staff to a resident's movements. Resident 1 care planned fall mat and body pillow were in place at the time of the event. Staff 6 reported not completely reading the care plan. The facility completed a plan of correction to include audits; staff re-education of placement of equipment and equipment monitoring. The audit results will be given to the facility QA committee. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +HM116825,385263,NF,4/26/2011,"On 4/26/2011 staff observed RV3 wheel self to the table with RV1 and touch RV1 under the table. Staff removed RV1 and reported behaviors with RV's care plan being updated. On 4/28/2011 W6 observed RV3 rub RV2's arm and other body part. RV3 was immediately removed and the care plan was updated. A PASR11 was performed for RV3 and recommendations made, but the family did not approve of its use. There have been care conferences with RV3's family, physician notification and various interventions tried.",2,0,Not Substantiated,Substantiated, +HM116949,385263,NF,5/5/2011,"RV was admitted to the facility without the facility securing the ordered Bi-PAP, Bi-PAP settings, Bi-PAP operating manual and ensuring all staff were properly trained to use the Bi-PAP. RV_x001A_s condition (congestive heart failure) deteriorated, staff were not able to apply the Bi-PAP as ordered, RV_x001A_s condition continued to deteriorate and RV was sent back to the hospital.",3,400,Substantiated,Substantiated,Neglect +HM117022,385263,NF,4/26/2011,"RP2 swatted RV with a rolled up paper/magazine after RV ""grabbed"" RP2's buttocks. RP2 immediately swatted RV a second time following the first swatting. RV did not sustain injury. The facility took immediate intervention. RP2's employment was terminated.",2,0,Not Substantiated,Substantiated,Physical Abuse +HM117040A,385263,NF,5/17/2011,"RV1 is unable to give relevant information due to his/her cognitive impairment. RV 2 was unable to recall who came in and turned off the call light without providing care. W3 and W4 (staff) reported that in the middle of a transfer of RV1 RP2's cell phone went off, RP2 quit the transfer and played with the cell phone. RV1 was placed at risk for significant harm when RP2 failed to follow a standard of care for a safe resident transfer. W3 and W4 reported that RP2 left to find another staff to help transfer RV1, although an earlier transfer using W3 and or W4 had occurred. RV1 was made to wait for toileting assistance and became incontinent. W3 and W4 reported that RV2 was wet with incontinence and RP2 made RV2 wait for 30 to 40 minutes for assistance even though RV2 kept using his/her call light. RP2 failed to provide care to RV1 and RV2 resulting in a significant loss of dignity and comfort.",2,0,Not Substantiated,Substantiated,Neglect +HM117040B,385263,NF,5/17/2011,"W3 and W4 reported RP2 used derogatory words toward RV2. W3 and W4 reported RP2 called RV2 "" a pain in the ass."" W3 reported RP2 was yelling at RV2 that RV2 did not need ice water. RP2 verbally abused RV2.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HM117497,385263,NF,7/19/2011,Both RV1 and RV2 are cognitively impaired and unable to give relevant information. W1 observed RV2 touch RV1's leg/ankle before W1 could intervene. RV2's care plan was not transferred to the 6/14/11 care plan and the old care plan was not followed. RV2 was to eat in the TV room and be kept 5 feet from other residents and visitors. Neither RV sustained injury or notable outcome. RV2's care plan was updated to reflect RV2's behavior and interventions.,2,0,Not Substantiated,Substantiated, +HM117993,385263,NF,9/13/2011,RP2 made an inappropriate comment to W2 within ear shot of RV. RV denies anyone made comments or cussed at RV. RP2 voiced frustration when other staff refused to assist RP2 with RV's care. Evidence is insufficient to support RP2 cussing at RV.,2,0,Not Substantiated,Substantiated, +OR0000707400,385263,NF,8/15/2011,"Resident 1 was admitted 6/18/11 for therapy and identified multiple diagnoses. Resident 1's care plan dated 8/10/11 indicated ""extreme risk"" for falls with interventions including a fall mat, tab alarm at all times and a call light within reach. On 8/13/11 at approximately 11:30 P.M. Staff 6 found Resident 1 on the floor of his/her room with the fall mat beside him/her. Subsequent evaluation at the hospital found Resident 1 had fractured his/her hip. Staff 3 completed an incident investigation indicating the ""alarm did not sound."" staff 6 reported it was the beginning of his/her shift and the alarm was "" not there"" when she/he found Resident 1 on the floor. As of 9/1/11 Resident 1's bedside care plan had not been updated to reflect the change to a Tab Alarm at all times. The August 2011 CNA flow sheet (ADL Care Plan) did not identify specific safety interventions. Staff 2 reported that CNAs knew what care plan interventions to use by observing what was in place at the time. The facility failed to ensure all staff knew and provided all care plan interventions to prevent accidents. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +HM118676,385263,NF,12/10/2011,"RV did not receive a shower or complete bed bath from 12/7/11 to 12/12/11. RV did state he/she receive a ""wash rag and wipe ya hither and yon."" evidence is not conclusive RV sustained a negative physical outcome. RV's colostomy bag was ordered to be changed PRN. The complainant stated he/she changed the ""bag."" W2 reported staff could/would have emptied the bag.",2,0,Not Substantiated,Substantiated, +HM118656,385263,NF,11/23/2011,"Resident #1 (RV1) was a resident of the facility (RP1) from November 18, 2011 until November 30, 2011 when he/she was taken home by family members. RV1 did not receive a shower until November 25. He/she received a bath on November 29. RV1 was observed numerous times in wet garments. At the time of discharge RV1's pants were wet. Pictures taken that evening showed RV1's bottom was bright red and the redness extended up the hips and down the left leg. On December 2, 2011 RV1 was diagnosed with a yeast infection and given medication. RP1's records did not reflect the presence of red skin or other skin injury. The facility failed to provide appropriate hygiene and toileting as required by the resident's care plan, resulting in damage to RV1's skin. RP1's failure was a violation of Oregon Administrative Rules and constituted abuse.",2,0,Substantiated,Substantiated,Neglect +HM129902A,385263,NF,4/24/2012,"Staff cleaned RV1's room, placed money in bedside drawer and money went missing. While staff observed RP2 in RV's room, evidence is insufficient to support RP2 taking RV's money. RV reported it ""doesn't make me feel good"". The facility did or will be reimbursing RV for the lost money.",2,0,Substantiated,Substantiated,Financial abuse +HM129902B,385263,NF,4/24/2012,"Witnesses and RV2, RV3 and RV4 reported RP2 being rough with care. RV2 reported RP2 ""throws"" him/her around like a sack of potatoes. RV4 reported over hearing RV3 say ""ow, you're hurting me"" and RV4 reported RP2 ""pulls and pushes--RP2 is ""just rough"" when changing RV4's brief. While RP2 denies the alleged roughness, preponderance of evidence finds RP2 is rough causing physical abuse of RV2, RV3 and RV4. The facility suspended and terminated RP2's employment for resident safety.",3,0,Not Substantiated,Substantiated,Physical Abuse +HM129902C,385263,NF,4/24/2012,"RV4 and W11 reported over hearing RP2 yell at residents when complaining that RP2 was hurting them. RV4 reported hearing RP2 more than once yell at RV3. W6 reported speaking with W11 when hearing yelling in RV2'W room and observing RP2 leave RV2's room.; W11 did not say who was yelling. Investigator interview with W11 stated RP2 has told RV3 to shut up when RV3 asked why RP2 was hurting them. Witness 12 reported hearing RP2 ""all the way down the hall"" heard RP2 tell RV2 ""you think you're such a big person, you can't even get out of bed"". W8 reported RP2 has been written up for verbal aggression because of RP2's tone. RP2 reported W8 had spoke with RP2 about being loud and RP2 stated he/she(RV2) was yelling at me. Preponderance of evidence supports verbal/emotional abuse of RV2 and RV3 by RP2.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HM120000,385263,NF,5/8/2012,"RV reported seeing money on the 6th and missing the money on the 8th. A locking drawer was available, RV chose to keep the wallet on his/her bed. There was still $5.00 (dollars) left in the wallet; a $50.00 bill was missing. Evidence is inconclusive whether or not the money was stolen. The facility replaced the money. The facility failed to provide a safe environment resulting in loss of RV's money. This failure represents abuse and an Oregon Administrative rule violation.",0,0,Substantiated,Substantiated,Financial abuse +OR0000755802,385263,NF,4/11/2012,Resident 1 was admitted 3/29/2012 with multiple diagnoses and assessed risk including 4+ edema of the lower extremities. Resident was admitted with physician ordered Furosemide 20 mg daily. Resident edema was not care planned and no documented evidence was found of monitoring the edema. On 4/5/2012 nurses notes disclosed staff observed the left leg was weeping and blisters to the lower leg were present. Staff faxed the physician without a documented response. The resident was sent to the ER at the family's request. Staff failed to monitor and provide care plan intervention for resident's edema other than minimal intervention. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000755803,385263,NF,4/11/2012,"Resident 1 was admitted 3/29/2012 with 4+ lower extremity edema. The admission care plan did not give staff specific direction to minimize potential skin injury while care was provided. Resident 1 sustained skin tears to the right lower leg and right forearm. Staff used a bath sheet to turn the resident which provide some intervention for his/her fragile skin, but direct care staff should have been given specific instruction to reduce skin risk, i.e.. Use of two staff, etc. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Neglect +HM120257B,385263,NF,4/30/2012,"The complainant reported the facility does not have a protection plan to deal with RV's behavior other than medication. RV's care plan of 2/26/2012 revealed intervention to keep RV 5 feet away form the opposite gender, witnesses reported only using 3 foot distance. Other care plan iinterventions were in place. Additionally RV1 and RV2 interaction was not properly reported to APS.",2,0,Not Substantiated,Substantiated, +OR0000832400,385263,NF,5/31/2013,The resident was admitted with multiple diagnoses. Resident's care plan identified transfers using a Hoyer lift. On 4/10/2013 during a transfer resident's Hoyer strap broke. Staff reported the sling was old and brittle. Staff denied knowledge regarding reporting damaged equipment to nursing staff. Since this event all staff received further in-service and laundry staff are to inspect the slings when they are laundered. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +HM145855,385263,NF,12/31/2013,"RV2 entered RV1's room and grabbed RV1's breast. RV2 had similar patterns of behavior in the past. Staff provided prompt intervention and placed a stop sign at RV1's door. RV1 was not physically harmed, but RV1's dignity and resident rights were grossly neglected. The facility failed to enforce RV2's care plan to monitor and not allow RV2 within 5 feet of the opposite gender. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000867001,385263,NF,12/16/2013,Based on interview and record review it was determined the facility failed to provide sufficient staffing. Relevant portions of the survey are attached. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000867000,385263,NF,12/16/2013,Resident 2 was admitted September 2009 with multiple diagnoses. Resident eloped from the facility during night shift November 2013 when outside temperatures were 25 to 32 degrees. The resident was placed in immediate jeopardy and this constitutes substandard care and abuse. Staff failed to supervise resident 2 and or ensure the door alarm was functioning at the time resident left the facility. Resident 2 was not adequately assessed or care planned for resident's wandering behaviors. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +HM147057,385263,NF,5/7/2014,RV wanders into other resident's rooms. RV's continued wandering and grabbing at resident belongings violated resident rights to privacy and choice in treatment. Staff were to provide one to one staffing are better at watching RV per W5. RV's medication was adjusted. Staff continue to work on a better placement for RV. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +HM147643,385263,NF,6/27/2014,"The complainant reported multiple concerns as noted in the attached public report. W1 also reported concerns regarding RV's care. RV did not sustain a fracture. Witnesses reported if you see a call light on you respond. RV reported an improper mechanical lift transfer resulting in pin. Staff did fail to follow RV's care plan, RV did not sustain injury. W7 failed to report alleged abuse and was counseled. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HM148457,385263,NF,8/31/2014,"RV has a history of abusing pain medication. Staff inadvertently failed to ensure the medication cart was locked. RV denies taking medication from the cart; RV did take syringes. Staff 5 failed to immediately report observing RV at the medication cart. RV's urine was negative for narcotics, but may have been a poor specimen. All staff received further in-service. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HM149176,385263,NF,8/30/2014,"The complainant and RV voiced multiple concerns as noted in the attached report. RV's drug test was negative for opiates, but witness report the UA was not an adequate sample. Staff did not watch RV provide the urine sample and there is the possibility RV's sample was mixed up at the lab. Many staff signed for and gave RV medication; given the number of staff it would not be possible all narcotics were diverted. Witness 2 reported RV's physician said RV would have been in ""terrible ""withdrawal if RV had missed narcotic medication for 48 hours. RV's treatment sheet indicated RV did not receive all physician ordered right lower leg wound cleanse with applied gauze daily in August. RV did receive ointment to the fight foot daily times two time seven days. RV's CBGs fluctuated from low to high; RV would eat sandwiches through out the night despite staff counseling. Oregon Administrative Rule violation occurred.",2,,Inconclusive,Substantiated, +OR0000912001,385263,NF,7/30/2014,Resident 34 was admitted to the facility in July 2014 and was his/her own responsible party. Resident 34 fell on 7/25/2014 at 9:30 P.M. Staff 9 failed to report the resident's fall to licensed staff because Resident 34 didn't seen to have any injuries. Resident's fall was not promptly investigated which placed the resident at risk for further harm. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule was violated.,2,,Not Substantiated,Substantiated, +HM151031,385263,NF,4/20/2015,"RV reported missing $13.00 in one dollar bills from his/her wallet, stated there were other times monies went missing and odes not know who may taken it. W2 confirms RV had monies in his/her wallet the day before the monies went missing. Reviewer notes RV filed a grievance regarding the missing monies on 3/30/2015, but the facility failed to report the alleged theft to LEA or APS. The facility did reimburse RV and provided additional lockable storage pleasing to the RV. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +HM151030,385263,NF,4/20/2015,"The facility failed to protect RV1 from RV2's unwanted tough. RV1 reported it was the only time RV2 had reached out and grabbed RV1. W1 reported being RV2's assigned one to one care giver, was approximately 8 feet away as RV1 passed by RV2 and RV2 grabbed RV1. Staff provided intervention and updated RV2's care plan to include monitoring behavior for triggers and removing triggers such as opposite gender in close proximity. Given RV2's past behaviors and RV2's speaking of sexual related matters all that morning, the event was likely foreseeable and preventable. The facility failed to provide a safe environment for RV1 and RV2 resulting in neglect of care and abuse. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +HM151028,385263,NF,4/17/2015,"Between 1/21 7 24/2015 a full card of RV2's narcotic medication went missing. The facility tested all employees with access to the medication cart at the time of the event; all tested came back negative for the medication in question. The facility failed to report the theft to APS. The facility called the pharmacy and replaced the medication although there was not documentation supporting this. Prior to the event staff had failed to count narcotics in an appropriate manner. Additionally staff reported the latch on the medication cart did not always function properly. Staff reported the cart would be left unattended at times as staff entered and exited resident rooms to distribute medication. RP2 was a suspect of interest, but RP2 denied taking the medication and when tested repeatedly RP2 was negative for narcotic medication. Additionally RV1's pain patch went missing at times, but evidence does not support theft of the patch as staff found RV1 chewing on the patch one time and another time clutching the patch. Staff will now frequently check for RV1's patch. The facility failure to provide a secure environment resulting in the theft of RV2's narcotic medication constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Financial abuse +OR0000973501,385263,NF,6/2/2015,On 5/19/2015 the resident was sent to an appointment without adequate oxygen. W4 reported the resident arrived at the appointment out of breath and the oxygen tank was empty. Staff reported checking the tank before the resident left. The facility failed to ensure the resident had adequate oxygen for the trip to the resident's appointment causing the resident shortness of breath and discomfort. The resident's neglect of care constitutes abuse. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0000973502,385263,NF,6/2/2015,Resident 1 was admitted 5/12/2015 with diagnoses including bilateral pulmonary emboli and physician orders including Lovenox. Record review noted the resident received Lovenox as ordered. The resident reports concern to staff regarding his/her abdomen condition and staff said it was normal. The resident saw the FNP on 5/19/2015 and was sent to the hospital with cellulitis of the abdomen; differentiated diagnosis of abscess versus hematoma. W4 reported not knowing if it was an infection or reaction to the Lovenox. The facility failed to fully assess the resident's abdomen and report the resident's concerns/condition change timely. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative rule violations occurred.,2,,Not Substantiated,Substantiated, +HM153247,385263,NF,9/18/2015,Three events with RV4 being the aggressor without adequate assessment and or intervention being timely. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +HM153640,385263,NF,9/30/2015,"The complainant reported RV is not assisted to the toilet timely and has been placed back in bed in clothing RV had gotten wet. The complainant also reported facility failure to provide a replacement meal for RV 1 and RV2 on 10/3/2015. RV1 corroborated the complaints. RV1 did report agreement to wait to use the toilet after dinner time. RV was placed at risk for harm after receiving insulin and not receiving a timely meal replacement. Staff alerted the kitchen to RV's request, but staff did not follow-up to see if RV received the requested replacement until over an hour later at which time RV had not received the requested sandwich. RV ate a brownie and then ate food W3 brought in for RV1 and RV2. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HM164947A,385263,NF,1/29/2016,"RV requested assistance to change his/her ileostomy appliance. RV's appliance came loose and was leaking stool onto RV's skin, clothing and bedding. RP2 brought supplies to RV, but believed RV was changing the appliance as RV was learning to do this. RP2 did tell licensed staff who were in the middle of a medication pass. A licensed nurse was required to change the appliance; not a C.N.A. RV waited over half an hour or more to receive requested assistance. RV was not afforded prompt incontinence care placing RV at risk for skin changes. RV's dignity was compromised by waiting for assistance while stool sat on RV's person, clothing and bedding. The facility failure to provide prompt incontinence care constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +BC116484,385264,NF,3/7/2011,"Resident 1 began exhibiting increased agitation and aggression in early March of 2011. The behaviors progressed to resident 1 yelling and kicking the front doors of the facility demanding to be let out. The facility felt that Resident 1 had the mental capacity to make his/her own decisions; however nursing staff did not agree. On 03/07/11 Resident 1 was allowed to sign discharge papers against medical advice. Resident 1 was repeatedly told that if he/she left the facility in this way he/she would not be allowed to return to the facility. Resident 1 was then assisted out of the facility in a wheelchair, was given a walker, and was released. + + + +Law enforcement personnel found Resident 1 walking in soiled pajamas and attempted to return Resident 1 to the facility. The facility gave Resident 1 a meal and 3 days medication, but refused readmission to the facility. The facility failed to prepare Resident 1 for discharge appropriately and to ensure a safe and appropriate discharge plan. This resulted in the potential for serious harm and constituted abuse. Furthermore, the facility denied Resident 1_x001A_s right to readmission, significantly violating Resident 1_x001A_s rights.",3,650,Substantiated,Substantiated,Neglect +OR0000685501,385264,NF,4/27/2011,"based on observation, interview and record review, it was determined the facility failed to follow Resident 5's physician orders. Resident 5 received his/her A.M. medication (Sinemet) at noon and therefore the noon does was unable to be given. Direct investigator observation found staff giving 8:00 A.M. medication past 10:15 A.M. The facility policy for passing medication was not followed. Staff 1's passing the medication was interrupted. The facility failed to ensure that it is free of medication error rates of five percent or greater.",2,0,Not Substantiated,Substantiated, +BC132222,385264,NF,1/20/2013,"On 1/20/2013 between A.M. and 2:30 P.M. narcotic count a full 30cc bottle of RV's narcotic went missing. RP2 gave RP3 keys which included keys to the medication cart. RP3 denied entering the cart; only using the key to go outside with resident to smoke. RP2 was busy with another resident in ""crisis"" and did not observe RP3 using the keys nor remembering who returned the keys to him/her. Neither RP2 or RP3 tested positive for the drug in question. RV did not go without medication. The facility replaced the medication and provided further in-service for staff regarding narcotics, duty of licensed staff and auditing narcotics. An Oregon Administrative Rule was violated.",2,0,Substantiated,Substantiated,Financial abuse +OR0000878700,385264,NF,2/18/2014,Resident 2 was admitted 20112 with multiple diagnoses. Resident received additional zinc tablets when staff gave a cup pills standing in the medication cart without ensuring they were to be used. The physician was notified and the resident vomited approximately 45 minutes later. Resident received further evaluation/monitoring without additional adverse effects. Staff failed to follow standard of practice. The facility failed to ensure a safe med system by having the unsecured medication in an open container in the med cart. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000883000,385264,NF,3/18/2014,"Resident 1 was admitted May 2013 with diagnoses including CHF. Resident's care plan of 5/15/2013 indicated choice of full CPR. Resident's 1/13/2014 POLST indicated CPR if found without a pulse or not breathing. On 3/16/2014 at approximately 6:45 P.M. Staff notified Staff 4 of the resident likely expired. Staff 4 assessed the resident and requested Staff 3 who re-assessed the resident. Staff 4 notified Staff 1 who directed staff to the POLST and 911 was then called. Staff5, Staff 4 and Staff3 did not promptly initiate CPR as the resident's care plan and POLST directed or as the facility policy directed. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC149597,385264,NF,11/2/2014,"The complainant, W3, W4 and W5 report falsified documentation indicating W3, W4 and W5 administered narcotic medication when they all report they had not done so. Discrepancies were found during narcotic count on 11/1/2014 including narcotics signed out on the narcotic sheet, but not initialed on the resident's MARs. Resident interviews were conducted and RV4 and RV5deny requesting any additional PRN narcotics. RV1 through RV8 were assessed and no changes were found in mood or pain level. RP2 was the common person with access to the narcotic medication and resident records from 6:00 A.M. to 11:20 A.M. on 11/1/2014. RP2 denied diversion of narcotic medication, but admits providing poor documentation. The pain management flow sheets are inconsistently completed in matching the front MARs for residents in question. Evidence is inconclusive to support RP2 forging documentation and diverting narcotic medication as other staff had access to the narcotics and resident records at the time of resident's narcotic medication went missing. The facility failed to provide an adequate medication system resulting in missing resident medication which constitutes abuse. The resident's were placed at risk for harm due to poor medication documentation. Oregon Administrative Rule violations occurred.",2,400,Substantiated,Substantiated,Financial abuse +BC159854,385264,NF,11/19/2014,"RV's dental note of 10/17/2014 indicated a heavy plaque, needing help, etc. W8 (medical professional) reported seeing RV a few times in last three months (dental notes of 10/17, 11/18 and 12/13/2014). W8 reported RV's teeth had excess plaque and food debris, more than one would expect from regular brushing; in a fairly short time RV's teeth have broken down and RV has had some recurrent decay; RV's oral breakdown has been faster than expected. RV's care plan identified RV's resistance to care at times and approach later if necessary to provide care. RV's care plan also included skin risk, incontinence with a two hour schedule for care and assistance as necessary to maintain good oral hygiene. W4, 5, 7 and 9 reported RV's clothing is not changed on a regular basis; and RV has been left in urine soaked clothes and or linens for prolonged periods of time as indicated by smell, RV developing a rash, etc. The facility failure to provide care services in a consistent manner resulted in RV's rapid oral decline, body rash and a significant loss of dignity as a reasonable person would not want to be left in urine soaked clothing. The facility neglect of care constitutes abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +BC150663,385264,NF,3/11/2015,"RP2 failed to provide multiple treatments including, but not limited to a dressing change, Foley catheter flush and body audits for multiple residents as described in the attached investigation report beginning 03/3 through 03/18/2015. RP2 reported being new to nursing (RP2 became a licensed RN on 12/24/2014) and began working at the facility on 02/12/2015 per W1. RP2 stated reporting to the DNS on the 3rd day that RP2 was over whelmed with the time frame and job duties; was told that gradually I would be worked into learning the treatments; assumed that it had been agreed on by the staff; and there was no follow-up. W1 reported RP2 had extended orientation. W4 reported training RP2 for four hours once, RP2 looked frustrated and RP2 was over whelmed. The facility failed to adequately supervise RP2 to ensure RP2 was able to complete treatments and care assigned to RP2; residents were at risk for harm. Oregon Administrative Rule violations occurred.",2,300,Not Substantiated,Substantiated, +OR0000955300,385264,NF,3/17/2015,"Resident 1 was admitted 3/22/2013 with multiple diagnoses as identified in the attached relevant portions of the survey completed 5/12/2015. the resident's MAR of March 2015 documented evening blood sugars ranging from 120 to 311. The resident's physician ordered 7 units of Lantus insulin on 3/15/2015. Facility staff gave the resident 70 units of Lantus after mis-reading the order. The resident's blood sugar remained with in the resident's usual parameters. The physician was notified, the resident received treatment and the resident was sent to the ER as a precaution. The resident did not sustain noted adverse effects from the additional insulin. The resident was at risk for potential harm. The staff making the error was a recent graduate. The facility took prompt measures to prevent a future error. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC152356,385264,NF,8/3/2015,"RP2 failed to follow RV's care plan for thickened fluids. Multiple staff intervened and stopped RP2 when RP2 refused to stop administering thin liquids to RV. RV was monitored for any adverse effects and none were noted other than an initial noted cough before staff stopped RP2's actions. RP2 admitted knowledge of RV's care plan for thickened liquids, failure to thicken the liquids and proceeded to give the thin liquids to RV. The facility took prompt and appropriate action to ensure RV and other resident safety. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0001027100,385264,NF,11/9/2015,"Resident 2 was admitted 8/2013 with multiple diagnoses including cognitive impairment. Resident's 7/2015 MDS Cognitive Loss and Falls CAAs noted confusion, impaired judgment and a history of falls. Resident 2 fell on 9/13, 9/15 and again n 10/10/2015 without adequate investigation and care plan updates. The resident fell on 10/14/2015 and sustained a fractured hip. The resident care plan was updated 10/20 and 10/21/2015. The resident fell on 10/27/2015; care plan interventions were not in place. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0001027101,385264,NF,11/9/2015,"Resident 2 was admitted 8/2013 with multiple diagnoses including cognitive impairment. The resident fell on 10/14/2015 and sustained a hip fracture. The resident was noted as non-compliant with hip precautions and was sent to the hospital on 11/6/2015 and a hip dislocation was confirmed. The resident had been complaining of intense pain from 11/7/2015 re-admission. The resident had not been compliant with hip precautions and by 11/8/2015 complained of intense pain; nurse practitioner(NP) and physician were not on resident status until 11/10/2015. Resident's behavior and complaints of pain increased without informing the NP until 11/15/2015 when resident family stated the hip was dislocated again. Resident 2 was in pain without adequate relief for several days. On 1/2/2016 a 9:20 P.M. nurse note documented Resident 2 complained of nausea, stating "" I threw up last night, am still nauseated, feeling really ill."" A chest x-ray was positive for pneumonia and the resident was sent to the hospital. Survey review indicates failure to fully assess and promptly report change of condition for Resident 2, 3 and 4 by staff 9, 10 and 33. The residents were placed at risk for further harm. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000720500,385265,NF,10/12/2011,"Resident 1 was admitted August 2011 with diagnoses including a fractured right ankle and Alzheimer's' dementia. The 8/26/2011 Fall Risk Assessment indicated a high fall risk and the 8/31/2011 bed side care plan was updated to indicate extensive transfer assistance using 1 to 2 CNAs and a gait belt. The resident found a lot of the time on the floor following a self attempted transfer. On 10/5/2011 two staff assisted the resident to the toilet when the resident suddenly stood up, legs weakened and staff lowered the resident to the floor. The resident sustained bruised knees. Staff failed to use the gait belt, but evidence is uncertain if the gait belt would have prevented the lowering of the resident. Staff 4 was new and orienting to the floor. Relevant portions of the survey are attached. Enforcement action was recommended. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +BH120416A,385265,NF,6/27/2012,"RP2 admitted she/he may have raised his/her voice in response to RV pinching RP2. Witnesses reported RP2 was a good care giver without prior incident, but was ""sometimes"" a little loud. RP2 failed to provide RV with all due respect by raising his/her voice to RV. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000689600,385266,NF,5/23/2011,"Resident 1 was admitted 4/25/11 with multiple diagnoses and physician orders for 40 mg of Lasix daily. Resident did not receive the Lasix as it was not transcribed to the MAR. Resident did not develop edema according to the nurses notes from 4/25/to 30/11. The facility conducted RN in-service with the RCMs and licensed nurses regarding resident admission orders, as well as, random monthly audits of original admission orders. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +OR0000795800,385266,NF,11/27/2012,"Resident 1 was admitted 4/17/2012 with multiple diagnoses including osteoporosis, anxiety, a history of falls, etc. The 7/4/2012 care plan provided fall interventions including 15 minute visual checks. Resident 1 sustained injury and non-injury falls on 7/7/2012 and 7/22/2012. The facility investigation found the 15 minute checks had not been completed as care planned at the time of the incidents. The facility provided further in-service and audits will be conducted weekly to assure compliance with care plans. Enforcement action was recommended. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000826200,385266,NF,4/26/2013,"Resident 1 was admitted 2009 with multiple diagnoses and care planned interventions to address fall risk. Resident care plan included two person assist for mobility and transfer. Staff 1 left the resident on the side of the bed while retrieving a Sara Lift. Evidence was not included for whether or not Staff 1 sought other staff assistance prior to leaving the resident at the bedside; stating he/she would be right back. Per incident documentation Staff 1 returned, heard the resident call out and found the resident on the floor. The resident sustained bruising, a skin tear and discomfort. Subsequent x-ray was negative for fracture. Relevant portions of the survey area attached. Enforcement remedies were recommended. Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +BH134561,385266,NF,1/7/2012,"RV was admitted 11/25/2011 with multiple diagnoses including a spinal fracture and orders for rehabilitation services. On 12/24/2011 RV sustained a leg wound during a transfer. Witnesses give conflicting statements as to whether or not the transfer was appropriate. No witnesses or documentation indicate falls or injury to RV's ribs. RV began to complain of chest pain and staff noted RV would refuse to get out of bed and required two people for transfer. RV was diagnosed with multiple rib fractures on and other conditions at a 12/29/2012 hospital visit. The facility failed to adequately assess and follow-up with interventions following RV's leg encounter with the wheel chair; RV's repeated complaints of pain and nausea. The facility failures constitute abuse. Given the age of the report a monetary sanction will not be imposed, but severity levels will be enforced. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +OR0000878000,385266,NF,2/14/2014,"Resident 11 was admitted March 2013 with multiple diagnoses. Resident's 4/9/2013 MDS documents cognitive impairment, communication deficits, dependent bed mobility and incontinence both bowel and bladder. Resident's 4/11/2013 care plan identified pressure ulcer risk, but failed to contain interventions. A 4/25/2013 skin assessment identified a Stage II pressure ulcer to the tail bone and attributed the ulcer to the resident not being turned. A 5/1/2013 intervention included repositioning the resident every two hours; not lay resident on his/her back. The facility failed to provide adequate care and services to prevent development of a pressure ulcer. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +BH150556,385266,NF,12/13/2014,"By interview and documentation review the facility failed to ensure RV received narcotic medication as ordered by his/her physician from 12/13/2014 afternoon admission through discharge on 12/14/2014 at approximately 12:30 P.M.-4:30 P.M. per the 12/14/2014 progress note. RV complained of severe pain, felt like RV's world was crashing down and feeling increasingly anxious and agitated at not having his/her medication. RV had received specific pain medication for over 10 years prior to this admission. W2 worked with staff in an attempt to get RV's specific medication, insisted the facility had received a 2 day advance notice regarding RV's specific medication and the facility should have had the medication on site to administer to RV. W4 (staff) reported RV received a substitute medication, but RV continued to complain of pain. The facility failure to ensure RV's narcotic medication was available for administration to RV resulting in RV's continued pain constitutes neglect of care and abuse.",3,350,Substantiated,Substantiated,Neglect +BH150752,385266,NF,1/26/2015,"RV was initially admitted on 12/13/2014 with physician ordered Heart Healthy diet and specific heart related medication to be taken daily. RV's heart related medication was discontinued without a physician order from 12/18/2014 to 12/23/2014. RV required hospitalization on 12/23/2014 for weakness and need for oxygen. RV was readmitted on 01/0202015 with a physician ordered heart related medication, but RV did not receive the medication from 01/02/2015 through discharge of 01/15/2015 per documented evidence. The facility failed to ensure RV received medication as ordered resulting in neglect of care constituting abuse. Oregon Administrative Rule violations occurred.",3,450,Substantiated,Substantiated,Neglect +BH151159,385266,NF,4/30/2015,"RV was admitted 2/13/2015 for rehabilitation, but is not safe to go home. In an interview conducted 5/5/2015 W1 reported RV had been exit seeking over the past month. RV exited on 4/30/2015 unassisted in his/her wheel chair, but then began walking without using the wheel chair. W2 reported one prior event. RV was placed on one to one supervision and RV's care plan was updated for safety. RV was unharmed, but at risk for harm. The event was foreseeable. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC116523A,385268,NF,3/4/2011,"RP2 reported ""trying to be helpful to someone else and transferred RV1 without using the Hoyer lift"". RP2 knew to follow the care plan and received further counseling. RV1 was not injured, but was at risk for injury during the transfer.",2,0,Not Substantiated,Substantiated, +OR0000678300,385268,NF,3/24/2011,"Resident 1 was admitted 3/21/11 with a diagnosis of sepsis of the right knee. Resident 1 was admitted with a PICC line for IV antibiotics. On 3/23/11 Resident 1's PICC line end cap was found to be missing; leaving the line open to air and Resident 1 at risk for an air embolism. Resident 1 was sent for evaluation and no embolism was found. Staff 10 was reported to be sleeping by multiple staff. Staff 3 reported Staff 10 stated ""he was tired"". Staff 10 was unable to recall if he replaced the end cap. Resident 1 was at risk for significant harm. The facility terminated Staff 10's employment and informed all licensed staff to reacquaint themselves with the Standards of Nursing Practice. Staff were also referred to the IV policy and Procedure Manual. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +BC116838,385268,NF,4/23/2011,"Evidence is inconclusive for exactly what RP2 said to RV. W1 and RP2 give conflicting statements as to the exact phrases used, but do agree on a least one thing; RP2 told RV to hurry and RP2's shift was ending. RP2 failed to treat RV with all due respect. The facility terminated RP2's employment.",2,0,Not Substantiated,Substantiated, +OR0000728200,385268,NF,11/16/2011,"Resident 1 was admitted 10-26-11 with multiple diagnoses. Resident's physician orders included oxygen orders. Resident 1's POLST provided specifics for treatment including CPR if no pulse or breathing. On 11/14/11 Resident 1 sustained a change of condition. Staff 7 was told of resident's change of condition as Staff 7 was finishing a telephone call, resident was provided oxygen and resident's oxygen saturation rose to 91%. The RCM took Resident 1 to his/her room, observed resident without a pulse and initiated CPR. Video footage indicated Staff 7 failed to enter the dining room to assess Resident 1 for 2 minutes and 38 seconds from the time Staff 3 reported resident's 73% saturation and unresponsiveness. 911 was not called for 7 minutes from the time Staff 7 entered the dining room. Staff 7 did not promptly respond to staff request regarding the resident. Given Resident 1's co-morbidities Resident 1 was placed on comfort care. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000783300,385268,NF,9/12/2012,Resident 1 was admitted 2011 with multiple diagnoses and the 8/29/2011 care plan indicated a fall risk. Resident interventions included use of a low bed and a bed side fall mat. On 9/4/2012 at 4:00 A.M. the resident was found at the bedside without noted injury; no fall mat in place. Staff 2 and Staff 3 failed to follow the resident's care plan and placed the resident at risk for harm. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +OR0000801000,385268,NF,1/2/2013,Resident 1 was admitted 7/19/2013 with diagnoses including a stroke. Resident 1 was assessed and care planned for a two person assisted transfer from bed to the bedside commode. The care plan addressed transfer to the wheel chair using a pivot transfer or slide board with one staff. On 12/30/2013 Staff 1 transferred the resident from the wheel chair to the commode by him/herself and the resident sustained bruising to their hand. Staff 1 had not read the care plan nor received required training by PT as addressed in the care plan before providing pivot transfer. Resident 1's care plan failed to address transfer from the wheel chair to the commode which was confusing when reading the care plan. Relevant portions of the survey are attached. Enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,0,Not Substantiated,Substantiated, +BC134254,385268,NF,8/25/2013,"RP2 did not follow RV's care plan of RV wearing a back brace during transfers. RV refused the brace and was going to self transfer according to RP2. RP2 reported feeling ""compromised"". All staff including RP2 were given instruction to follow RV's care plan. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000838400,385268,NF,6/28/2013,"Resident 1 was admitted December 2011 with multiple diagnoses. The resident care plan of 7/19/2012 identified incontinence, fall risk, etc. and varied interventions were identified. A 5/10/2013 RCM summary identified the resident as generally continent and able to make needs known. Resident 1 was found on the floor on 6/25/2013 at approximately 5:45 A.M., stating no response to his/her call light and could not wait any longer. Video footage detailed resident call light at 5:08 and answered by Staff 6 at 5:19 A.M. Staff 6 stayed in the room approximately 30 seconds and the call light was reactivated at 5:23 A.M. and not answered until 5:45 at which time the fall was noted. Staff 6 reported a different scenario of events. The facility failed to provide care and services. Relevant portions of the survey are attached. Enforcement action was taken. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000859901,385268,NF,10/25/2013,Resident 1 was admitted 10/21/2013 with diagnoses including multiple sclerosis. The resident assessment indicated leg weakness and a history of falls. Staff 1 transferred the resident on 10/21/2013 without use of a gait belt per a basic nursing care procedure given to staff. The resident fell without noted injury. Staff 1 received further counseling and all staff were reminded of the importance of using a gait belt. Relevant portions of the survey are attached. Federal enforcement action was recommended. An Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000646000,385270,NF,11/9/2010,"On 11/4/10 following an ER visit Resident 1 was admitted with multiple diagnoses including gout, post MVA and arthritis. The therapy assessment of 11/5/10 revealed Resident 1 was tolerant of up right sitting for less than 5 minutes. On 11/8/10 Resident 1 sustained a change of condition and transferred to the ER via a taxi wheel chair transport. Resident 1 was sitting up beyond 8 minutes resulting in a significant amount of pain for Resident 1. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated,Neglect +OR0000646001,385270,NF,11/9/2010,On 11/8/10 Resident 1 was transferred to the ER without notifying Resident 1's health care representative of Resident 1's change of condition and hospitalization. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000653800,385270,NF,12/13/2010,"Resident 2 was admitted 4/14/06 with multiple diagnoses including UTIs, osteoarthritis and hypertension. The 7/14/10 MDS revealed Resident 2 was non-ambulatory, required extensive assistance with mobility/transfers, was incontinent of bowel, had a catheter and did not have any pressure ulcers. Resident 2's care plan noted skin at risk with numerous interventions. On 9/21/10 a Stage II ulcer was found on the right thigh. Resident 2's care plan was not updated to reflect the change of condition and required further intervention. Resident 2's condition deteriorated further with increased wounds and sepsis. The facility failed to adequately monitor and provide adequate over sight as a resident's condition changed. Relevant portions of the survey are attached. A federal civil penalty was proposed.",3,0,Substantiated,Substantiated, +BF103430,385270,NF,2/5/2010,"Poor communication between RV's RCM, charge nurse and pharmacy resulted in RV missing 8 doses of a red blood cell production stimulating medication. RV was to receive this particular medication 3 times per week, but pharmacy sent medication only if the facility signed a consent to pay. Miscommunication occurred when facility staff failed to send a signed consent each time the medication was ordered. While RV did not sustain ""direct"" adverse effects, RV's hemoglobin did decrease representing a preventable change in RV's condition.",2,0,Substantiated,Substantiated,Neglect +BH116729,385270,NF,3/30/2011,Multiple facility staff failed to properly transcribe all physician orders and/or ensure previously transcribed orders for March became part of the April MARs. RV did not receive all physician ordered bowel care resulting in RV becoming constipated. RV required x-rays for evaluation and further treatment was given.,2,300,Substantiated,Substantiated,Neglect +BH117139,385270,NF,6/3/2011,"RV's care plan was not specific in regard to assisting RV with a shower. RV can be combative with care with RV's care plan telling staff to ""back off"" and ""re-approach"", which was not practical when RV was in the shower. W3 reported he/she would work on interventions specific to showering RV. While RV has a small bruise to his/her thumb, evidence fails to support staff to resident abuse. RV likely injured self when he/she became combative in the shower.",2,0,Substantiated,Substantiated,Neglect +BH117140B,385270,NF,6/2/2011,"RV1 made a statement on or about May 20, 2011 regarding RV2's sexual assault. Staff were aware of the allegation and failed to promptly report or investigate the allegation in a timely manner. W2 spoke with W1 on 6/2/11 and RP1 initiated and investigated the allegation, as well as, reported to APS.",2,0,Not Substantiated,Substantiated, +OR0000695200,385270,NF,6/22/2011,Resident 1 was admitted 10/2009 with multiple diagnoses and assessed risk for falls. Resident 1's care plan identified interventions including not to be left alone on the toilet. On 6/21/11 Staff 2 left Resident 1 on the toilet to go and assist another resident who was yelling and was also a fall risk. Resident 1 was found on the floor and subsequent evaluation found a fracture. The facility failed to ensure staff followed Resident 1's care plan and or gave staff adequate instruction on what to do when presented with two residents in need of fall preventive care. Staff 2 received a reprimand for not providing the stand by care for Resident 1. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +OR0000703800,385270,NF,8/1/2011,Two staff provided transfer for Resident 1 without using a gait belt as care planned. The staff reported the belt was not big enough and neither thought to connect two belts until after the non injury fall. Resident 1's care plan was revised to use a 72 inch gait belt that was to be left hanging in Resident 1's room.,2,0,Not Substantiated,Substantiated, +BH117780,385270,NF,8/7/2011,RV's toilet overflowed during the night. RP2 placed towels to soak up the water and reported he/she did not enter the bathroom. Staff failed to thoroughly clean up all the water which presented a fall hazard to RV.,2,0,Not Substantiated,Substantiated, +BH117938,385270,NF,8/27/2011,The facility failed to ensure an appropriate medication system was in place regarding resident narcotics and appropriate documentation. RP2 acknowledged failure to accurately document all times residents were given medication. Evidence is insufficient to support resident harm. The facility counseled RP2 and OSBN was notified.,2,0,Not Substantiated,Substantiated, +OR0000712300,385270,NF,8/30/2011,Resident 1 was admitted 8/23/11 with diagnoses including traumatic brain injury. A safety assessment indicated a decreased alertness. Resident 1's care plan reflected use of a pressure alarm and a TAB alarm when up in the wheel chair. On 8/29/11 Resident 1 was found on the floor uninjured; no alarms were in use. Staff 1 admitted failing to look at Resident 1's care plan before assisting Resident 1 to the wheel chair. The facility terminated Staff 1's employment and provided further in-service to all staff regarding care plans. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000734900,385270,NF,12/15/2011,On 12/8/2011 Staff 1 (new CNA) followed the direction of Staff 3 (Occupational Therapist) to perform a one person transfer. Staff 1 reported telling Staff 3 he/she did not know Resident 1 and that Staff 1 was covering for someone else. Staff 3 reported not knowing Resident 1's care plan specifically called for a two person transfer. Staff 3 confirmed telling Staff 1 to do the transfer alone and left the room. Staff 1 lowered the Resident to the floor during the transfer and the G-tube valve came loose. Resident 1 did not sustain injury or negative effect; the valve was cleaned and replaced. Resident 1 was at risk for harm.,2,0,Not Substantiated,Substantiated, +BH129800,385270,NF,2/27/2012,"RP2 responded in a joking manner with RV about refusing services and getting ""wooden teeth"". RP2 reported winking at RV and RV winking back. Outside observers reported RP2 treated RV in a condescending and demeaning manner. RP2 failed to allow RV the right to refuse service in a less than professional manner. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +BH120003,385270,NF,5/5/2012,"RV reported he/she is happy with her/his care. RV reported call lights are usually answered within 5 minutes, but there was an occasion that took maybe an hour. Staff reported they were showering another resident and it took approximately 15 to 20 minutes. RV denied any problem with slow response time. RV was at some risk due to impulsive behavior. The facility failure resulted in a Oregon Administrative rule violation.",2,0,Not Substantiated,Substantiated, +OR0000760300,385270,NF,5/3/2012,"Resident 87 was re-admitted April 2012 with multiple diagnoses. A care plan dated 4/28/2012 indicated a Hoyer lift transfer. Another review of 5/3/2012 revealed use of two people to assist with the Hoyer lift transfer. Staff reported the Hoyer ""tipped over"" during a two person transfer to a gurney. Staff 39 reported never receiving formal training in use of the Hoyer. Staff 15 was not sure about specific Hoyer training or the lift being used. Resident 87 sustained a closed head injury. Relevant portions of the survey are attached. A federal civil penalty was proposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +BH116905,385270,NF,4/29/2011,"Between 4/29/2011 and 4/30/2011 RV's blood thinner was not given as ordered. RV received medication on 4/27 & 28/ 2011. RV's physician had seen RV in the physician office and the physician was going to write n order to hold the medication, but had failed to do so at the time of the error. Staff failed to order the medication in a timely manner and failed to notify the on coming nurse that the medication had not been given. RV did not sustain any harm.",2,0,Not Substantiated,Substantiated, +BH120822,385270,NF,8/3/2012,"W1, W2 and RV reported RP2 ""slapped"" RV's stomach multiple times. RV reported it ""hurt"". W2 observed RV to wince with each ""slap."" Additionally W2 reported RP2 stated to RV ""oh RV, you have a big old stomach."" RP2 treated RV roughly and with verbal disrespect. RP2/s behavior constitutes abuse. RP2's employment was terminated. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated,Physical Abuse +BH120968,385270,NF,9/4/2012,"RV1 reported on 9/4/2012 and 9/11/2012 the facility ran out of portable oxygen causing RV1 to ""miss out on big plans"" outside the facility and ""feeling trapped"". W6 confirmed the facility ran out of portable oxygen tanks on several occasions. RV4 and RV 5 confirmed the facility was out of the portable tanks on 9/3/2012. RV2, RV3 and RV6 were not able to be interviewed. While witnesses give conflicting statements, the majority of witnesses confirm a shortage of portable oxygen tanks. Insufficient portable oxygen hinders residents requiring oxygen the ability to freely move about the facility, as well as, to go for outside excursions. Additionally lack of portable oxygen for emergency use, places all residents at risk for harm. The facility was advised of the lack of oxygen tanks on more than one occasion before taking necessary steps to prevent a shortage of portable oxygen tanks.",2,200,Not Substantiated,Substantiated, +BH129774,385270,NF,4/10/2012,"RV's physician gave a new order for medication on 3/1/2012. Between 3/1/2012 and 3/15/2012 RV refused the medication. RV's physician gave orders on 3/15/2012 that the medication could be given in food or fluids. Staff attempted to give the medication a number of ways before RV accepted the medication in coffee. The medication was discontinued on 4/10/2012. RV was not fully informed of the medication RV was receiving at the time RV received medication in coffee. RV was making his/her own decisions, but RV was not afforded due process in deciding to take medication in coffee. The facility failure is an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000806600,385270,NF,1/23/2013,"Resident 1 was admitted October 2011 with diagnoses including dementia. Resident's nursing notes revealed the resident had falls on multiple occasions. The investigations were completed per Staff 2, but are now missing. The facility failed to ensure completed fall investigations were in the resident's medical record. Portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000806602,385270,NF,1/23/2013,"Resident 1 was admitted October 2011 with diagnoses including dementia and chronic pain. Resident assessment of 10/26/2012 identified weight at 231.2 pounds. A physician order dated 11/2/2012 directed staff to weigh the resident weekly on Fridays. The 11/5/2012 Nutritional Risk Assessment identified increased nutritional risk. The resident care plan provided interventions including meal monitoring and weights. Review indicated 42 instances the meal consumption was not recorded. All weights were recorded. The resident did lose some weight. The resident indicated he/she did not like the facility food. There is no indication of further assessment, care plan revision or referral being completed. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +BH121816,385270,NF,12/5/2012,RP2 repeatedly bartered and or paid RV for RV's narcotic pain medication. RP2 was in a position of power to wield power over RV. Evidence does not support RV sustaining continued pain. RV's medication was taken by RP2 for his/her personal use which constitutes abuse by theft. An Oregon Administrative Rule violation occurred.,3,,Inconclusive,Substantiated,Financial abuse +OR0000949902,385270,NF,2/18/2015,Resident 1 was admitted 10/20/2014 with diagnoses including a fractured femur and no identified pressure ulcers. On 12/17/2015 the resident was identified with a left heel wound. The resident did not receive adequate skin assessment or timely assessment in weeks to follow. On 1/5/2015 the resident was identified with a bunion wound and following assessments were inadequate as well as sporadic. On 1/12;/2015 a right heel wound was identified; again the assessment was inadequate and reassessment was sporadic. Lack of adequate skin care and services related to skin care constitute neglect and abuse. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative rule violations occurred.,3,,Substantiated,Substantiated,Neglect +BH153462,385270,NF,8/15/2015,The facility failed to provide and or maintain adequate care equipment resulting in an injury during RV's transfer. RV was discovered with a bruise/lump to RV's head which the facility determined occurred during a transfer. The facility found RV's mattress/bed were crooked and replaced. RV's injury was preventable constituting neglect and abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0001007804,385270,NF,9/24/2015,"Evidence and interviews failed to indicate facility failure to provide Resident #48 adequate care and services related to wound care. Evidence and interviews indicated facility failure to develop a comprehensive care plan for Resident #40 and Resident #43 reviewed for non-pressure skin care and unnecessary medications. In addition, evidence and interviews indicated facility failure to provide adequate monitoring of a splint device with development of a non-pressure skin condition for Resident #43. These failure placed residents at risk for unmet needs, relevant portions of the complaint report investigation are attached.",2,,Not Substantiated,Substantiated, +OR0001007805,385270,NF,9/24/2015,"Evidence and interviews indicated facility failure to ensure Resident #48 had correct health information (incorrect diagnoses) when attending a physician appointment on or about 6/6/2014. Evidence and interviews indicated facility failure to allow Resident #82 choice with her/his bathing schedule placing Resident #82 at risk for a diminished quality of life. In addition, evidence and interviews indicated the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Facility failure to provide a clean, comfortable, and orderly environment puts residents at risk for unmet needs; relevant portions of the complaint report investigation are attached.",3,,Not Substantiated,Substantiated, +BH132744,385270,NF,3/22/2013,RV spit out and saved morphine tablets during the time RV was receiving morphine. Staff failed to ensure RV consumed all medication RV received. Failure to ensure RV consumed all medication at the time RV received the medication placed the RV at risk for harm. RV was offering confiscated medication to others. Staff found 138 white tablets and 48 blue pills of morphine. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000663602,385271,NF,1/25/2011,Based on evidence and interviews facility failed to thoroughly assess and care plan for Resident #1's risk of dehydration. Relevant portions of the survey report are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000663604,385271,NF,1/25/2011,Evidence and interviews indicated facility failed to respond to Resident #1's change of condition in a timely manner. Relevant portions of the survey report are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000716600,385271,NF,9/19/2011,Evidence and interviews indicated facility failed to provide adequate care and services regarding Resident #1's fall with injury on 9/15/2011. Relevant portions of the complaint report investigation are attached.,2,0,Substantiated,Substantiated,Neglect +OR0000733801,385271,NF,12/8/2011,"Evidence and interviews indicated facility failure to administer Resident #1's medications per physician orders. Resident #1 was not administered her/his diuretic medication on 8/22/, 8/23, 8/24 and 8/25/2011, resulting in Resident #1 sustaining elevated blood pressure.",2,0,Substantiated,Substantiated,Neglect +BH120348,385271,NF,6/18/2012,On 06/18/2012 Resident #1 became upset with RP2 (CNA). Resident #1 said that RP2 hit her/him; however there was no documented evidence of injury from what occurred. Resident #1 said she/he became incontinent because she/he was scared of RP2's treatment of her/him. The facility's internal investigation determined RP2 failed to provide Resident #1 the level of care expected of employees.,2,0,Substantiated,Substantiated,Neglect +BH165264,385271,NF,12/13/2015,Evidence and interviews indicated facility failure to protect Resident #1 from emotional abuse by RP2 (Licensed Nurse) on or about 12/12/2015. The facility failure to protect Resident #1 from emotional abuse resulting in Resident #1 sustaining emotional distress are violations of resident rights and constitutes emotional abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HB105507,385272,NF,10/20/2010,"RP2 borrowed money from RV on more than one occasion, but failed to pay all the money back to RV. RV is alert/oriented and gave the money to RP2, but then RV came up short for his/her rent money. RP2 had received in-service regarding abuse; specifically financial abuse. On 10-20-10 RP2 admitted to W2 that RP2 had borrowed money from RV. As soon as RV reported the money issue the facility terminated RP2's employment and notified SPD.",2,0,Not Substantiated,Substantiated,Financial abuse +HB105793,385272,NF,12/6/2010,"RV reported asking for two pain medications ahead of time and only 4 times has he/she received them in under an hour. RV reported asking 12 times for medication and not receiving it. RV reported other medication issues including missing a dose of medication. Staff reported an issue with RV's insurance, resolved the issue and gave RV medication from the E-kit. W4 reported RV did not receive a medication due on 12/4/10 as not having the prescription; staff were waiting on a new prescription. RV received a split dose of medication on12/6/10, although RV's medication record did not reflect this. RV did miss a dose of medication.",2,0,Not Substantiated,Substantiated, +OR0000710102,385272,NF,8/23/2011,Resident 1 did not receive ordered bowel care in July per MAR review. Resident 1 was at risk for harm. Further staff in-service will be conducted with all CMAs. Relevant portions of the survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000720601,385272,NF,10/12/2011,"Resident 1 was admitted 2011 with diagnoses including paraplegia. The 6/9/2011 Skin Impairment form revealed Resident 1 was admitted with a pressure ulcer to the outer right knee; Stage II and a Stage II to the coccyx. The 6/17/2011 care plan indicated various interventions for the ulcers. Documentation of 9/27/2011 indicated the coccyx ulcer was closed and knee ulcer was smaller. The TAR review found physician orders, but no physician notification or new orders when Resident 1 fell 10/2/2011; reopened the knee/buttocks ulcer. Dressing changes were not completed 10/2/2011 through 10/7/2011. resident 1's ulcers deteriorated and no new physician orders were received until 10/26/2011. The knee ulcer began to resolve 10/31/2011. staff 6 reported many new staff and documentation was not always completed. Resident 1's ulcers improved and Resident 1 was discharged 11/9/2011. relevant portions of the survey are attached. Enforcement action was recommended.",2,0,Not Substantiated,Substantiated, +OR0000720604,385272,NF,10/12/2011,Resident 1 reported calling for help and no one came to offer assistance. Resident 1 indicated the call light went unanswered for 45 minutes. Resident council meeting notes indicated residents felt the call lights were answered timely. An in depth in-service with all staff was given 12/22/2011. Relevant portions of the survey are attached. Enforcement action was proposed.,2,0,Not Substantiated,Substantiated, +OR0000720605,385272,NF,10/12/2011,No documentation was found confirming Resident 1 or family were invited to attend a care conference after the 9/20/2011 MDS assessment. Staff did assist Resident 1 with his/her discharge. Relevant portions of the survey are attached. Enforcement action was recommended.,2,0,Not Substantiated,Substantiated, +OR0000729500,385272,NF,11/21/2011,Resident 1 was admitted mid May 2011 with multiple diagnoses and assessed at a high fall risk; impaired cognitive status; and poor safety awareness. Initially a tab alarm was used when Resident 1 was in bed or the wheel chair. The alarm was discontinued August 2011 and re-instated 11/12/2011. on 11/15/2011 Resident 1 fell again and sustained a fracture. The care plan was updated again on 11/15-16/2011. Direct surveyor observation of 12/19/2011 found Resident 1's care plan not being followed; alarm and mat not in place. Resident 1 was again at risk for further harm. Relevant portions of the survey are attached. A federal civil penalty was proposed.,3,0,Substantiated,Substantiated,Neglect +HB129041,385272,NF,1/23/2012,"RV perceived RP2 as abrupt/yelling at RV. RP2 denies saying anything to upset RV; reported RV was not ""wet."" RP2 has a history of abruptness and not realizing how she/he comes across to residents per W2 and W3. The facility failure to ensure RV was treated with all due respect; and facility failure to thoroughly investigate and or write a incident report is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated, +HB129042,385272,NF,1/18/2012,"RV's care plan indicated transfer assistance. RP2 and RP3 used a Hoyer lift and the sling strap pinched RV's leg. RP2 and RP3 reported stopping the transfer when RV complained it hurt. W6 reported the care plan was not specific to use of a Hoyer lift; it is assumed it was part of what is referred to in the care plan. RP2 reported the slings for different Hoyer lifts have differences. RP2 denies knowing exactly what occurred, but W4 reported crossing the straps with the lift that was used would not be correct. The facility up dated RV's care plan to address his/her behavior. Further staff in-service was given regarding the different lifts and straps. The facility failed to have a safe environment which is a violation of the Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated, +HB129773A,385272,NF,4/12/2012,"W4 reported to W2 (per witness statement of 3/26/12) that RP2 was not going into RV1 and RV2's room. RV1 did not receive feedings and medication during RP2's shift on 3/26/2012, 3/27/2012 and 4/6/2012. Witnesses reported RP2 did not enter RV2's room on 3/27/2012 and RV did not receive feedings or a specific anti-seizure medication. W1 failed to review the Narcotic Medication Sheet until 4/6/2012; finding RP2 failed to administer RV2's anti-seizure medication on 3/26/2012, too. Although facility administrative staff had facility staff watch RP2, the facility failed to provide timely and appropriate intervention to ensure RV1 and RV2 were receiving ordered medication and nutrition. RP2 denies neglect in feeding RV1 and RV 2. W4 reported RV1 looked miserable. RV2's seizures developed into full seizures between 3/28/2012 and 4/7/2012. RP2's failure to provide care as ordered and the facility failure to provide appropriate and timely intervention resulting in a resident's change of condition which constitutes abuse and an Oregon Administrative Rule violation.",3,300,Substantiated,Substantiated,Neglect +HB129773B,385272,NF,4/12/2012,"W4 reported to W2 (per witness statement of 3/26/12) that RP2 was not going into RV1 and RV2's room. RV1 did not receive feedings and medication during RP2's shift on 3/26/2012, 3/27/2012 and 4/6/2012. Witnesses reported RP2 did not enter RV2's room on 3/27/2012 and RV did not receive feedings or a specific anti-seizure medication. W1 failed to review the Narcotic Medication Sheet until 4/6/2012; finding RP2 failed to administer RV2's anti-seizure medication on 3/26/2012, too. Although facility administrative staff had facility staff watch RP2, the facility failed to provide timely and appropriate intervention to ensure RV1 and RV2 were receiving ordered medication and nutrition. RP2 denies neglect in feeding RV1 and RV 2. W4 reported RV1 looked miserable. RV2's seizures developed into full seizures between 3/28/2012 and 4/7/2012. RP2's failure to provide care as ordered and the facility failure to provide appropriate and timely intervention resulting in a resident's change of condition which constitutes abuse and an Oregon Administrative Rule violation.",3,300,Substantiated,Substantiated,Neglect +HB120325,385272,NF,6/18/2012,"RV has not received a medication as ordered. One time RV was sleeping and difficult to arouse. Another time (June18, 2012) the medication was not given due to an insurance issue. The facility has arranged to pay for the medication. The facility has not asked RV's physician to write and ask for an exception. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +HB120486,385272,NF,7/10/2012,"The facility failed to maintain an accountable system for RV's money. Evidence supports inaccurate count and questionable documentation of RV's money. Evidence is insufficient to prove theft of money, but the facility failed to immediately report money concerns of 6/25/12; reported 7/10/12. The facility failure represents a Oregon Administrative Rule violation.",2,0,Inconclusive,Substantiated, +HB132127,385272,NF,1/12/2013,"The facility failed to provide RV1 with ordered IV medication/treatment on 1/10/2013 due to trouble inserting an IV needle. W2 came on shift 1/12/2013 and was able to insert the IV needle and administer the medication. There was no known negative effect or potential negative outcome for RV1 receiving the monthly treatment two days later than scheduled. RV2's tube dietary formula was ordered for 24/7, but delayed as the facility did not have the type of formula RV2's physician ordered. RV2 did receive other dietary supplement as ordered. There was no known negative effect to RV2. the facility failure represents Oregon Administrative Rule violations.",2,0,Inconclusive,Substantiated, +OR0000813902,385272,NF,2/26/2013,"Resident 1 was admitted 2010 with multiple diagnoses. Resident reportedhis personal wheel chair had been gone for months. A 1/24/2013 nursing note indicated the wheel chair was still out for repair. A social service note of 3/8/2013 indicated the resident still waiting for the wheel chair to be repaired. On December 2013 a tech took resident's wheel chair for repair and gave the resident a ""loaner"". Staff failed to follow up with the wheel chair repair company in a timely manner. The resident was not given adequate choice in the wheel chair he was to use for over an extensive period of time. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +HB132676,385272,NF,3/10/2013,"RV sustained minor foot pain after RV's foot ""smacked"" between the wheel chair and door frame due to a loose tray table bumping the wheel chair controls. RV had told staff back in January about the table. W3 was unable to recall exactly when RV complained the tray was loose, but did change the screws after the event. W3 was supposed to repair the loose tray prior to the incident, but did not complete the repair as the screws came in after the event. W5 reported telling a number of staff about the loose tray. The facility failed to provide a safe environment resulting in resident harm. An Oregon Administrative Rule violation occurred.",2,0,Substantiated,Substantiated,Neglect +HB133991,385272,NF,8/2/2013,"W1 heard RP2 say ""Stop hitting me""; heard a ""smack""; observed RP2 exit RV's room and state ""I just hit RV""; immediately entered RV's and observed a spot on RV's arm with a hand print on it. W1 further stated RV was very combative the rest of the night. W2 reported RP2 came into his/her office and said ""I am here to turn myself in"" and said ""I have to report I hit [RV1]"". The facility incident report indicated RP2 struck RV's upper left arm, but the progress/chart note for RV indicated a ""discolored area on the left forearm mid way between the wrist and shoulder on the dorsal affect area approximately the diameter of 3 inches in length and 2.5 inches in width noting a pink color and blotchy . A hand written note by RP2 dated 08/01/2013 indicated RP2 slapped RV's left forearm. RP2's action constitute physical abuse. The facility took immediate and appropriate action to protect RV and other residents. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated,Physical Abuse +OR0000850100,385272,NF,8/29/2013,"Resident 1 was admitted 8/9/2013 with multiple diagnoses including skin wounds. Resident was admitted with skin treatment orders, but no wound treatment orders for the scalp, right hand and foot. On 8/10/ 2013 staff completed skin assessment, except scalp, right hand and foot wounds. The resident physician assessed the resident on 8/15/2013 and ordered skin/wound treatment. The wounds were healing by 8/22/2013 per physician notes. Relevant survey pages are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HB135179,385272,NF,11/25/2013,"Staff heard, but did not directly observerv1 and RV2's altercation. RV1 tipped RV2's wheel chair causing RV2 to fall to the floor. RV2 sustained some knee pain; no further injury. RVs engaged in a prior event approximately 5 to 6 months before without noted injury. Witnesses report RV2 can be an ""instigator"". The facility failed to provide adequate care plan interventions addressing RV1 and RV2's behaviors resulting in a second incident between RV1 and RV2. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +HB145588,385272,NF,1/6/2014,"W1 reported no prior altercation between RV1 and RV2. RV1 entered the dining room, approached RV2 and RV2 struck RV1 approximately three times. RV1 did complain of some pain, but no outward sign of injury was noted. RV2's problem dated as 11/1/2010 in RV's care plan noted temper, striking at others, redirection, but this did not happen resulting in RV2 striking RV1. RV1 and RV2's care plan were adjusted following this event to address RV1's behavior /safety and RV2's poor impulse control, etc. The facility failed to adequately supervise RV2. Staff had not been instructed to monitor RV2 more closely prior to RV1 and RV2's incident which allowed this resident to resident altercation. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +HB147249,385272,NF,5/30/2014,"RV left his/her room for less than one hour, returned to find his/her lap top and smart telephone missing. RV has a lockable drawer that the telephone will fit in, but the lap op is too big to fit. The facility video did not show anyone entering the room. Staff had observed the equipment within the hour before it disappeared. The facility failed to provide adequate lockable space for RV's personal items resulting in theft of the items. The facility will be replacing the stolen items and installed a locking cupboard to hold the equipment. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Financial abuse +HB152226,385272,NF,7/24/2015,"RV reported RP2 attempted to give RV a ""specific"" medication other than RV's narcotic pain medication. RV gave the pills to facility staff that RV kept from the time RP2 attempted to give RV the ""specific"" pills. RV reported challenging RP2, RV demanded to see the narcotic card, RV reported seeing two pills left in the card and RV demanded RP2 give RV another two pills. RP2 denied dropping any pills and denied attempting to give RV other medication. Staff report no other resident in the facility was taking the ""specific"" medication. RP2 stated he/she used to take the ""specific"" medication. Preponderance of evidence finds RP2's actions constitute abuse. Multiple witnesses report RP2 was terminated from employment. The facility failed to notify law enforcement regarding theft of narcotic medication. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Financial abuse +OT120178,385273,NF,1/30/2012,"RV was showing signs and symptoms of change of medical condition and was being treated for such per W4. On 1/30/2012 RV attended a MD visit, received a new medication order and an order for a chest x-ray. Facility staff implemented the medication order changes, but failed to provide any follow up regarding RV's chest x-ray until W6 mentioned something to W4 on 2/3/2012. Additionally, staff failed to document in RV's medical record any notes regarding RV's physician visit of 1/30/2012 or the outcome related to new orders or follow up on the chest x-ray. RV was transferred to the ER on 2/4/2012 after developing fever, etc. and the FNP at the physician office was called. The FNP found the x-rays results noting pneumonia; the facility had no knowledge of the x-ray results until this time. The facility failure to promptly follow up on the results of RV's x-rays resulted in delayed treatment of RV's pneumonia, a further change in RV's medical condition (fever, increased lethargy, changes in lung condition as evidenced by decreased lung sounds, etc.) and placing RV at great risk for serious harm. This failure represents neglect and an Oregon Administrative Rule violation.",3,300,Substantiated,Substantiated,Neglect +OT148394,385273,NF,7/1/2014,"RV is unable to recall the event, but did report other than kind remarks from RP2 regarding RV's call light use. There was no response from W1 who remarks according to a facility interview. RP2 reported words were taken out of context. The facility failed to timely report suspected abuse. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OT148420,385273,NF,8/8/2014,"W3 assisted RV on the 7th, observed RV's hands on the 7th and denied seeing any injury until coming back on shift on the 8th. W4 assisted RV to transfer the A.M. of the 8th and denied observing any injury until after breakfast when RV stopped to ask for a ban aid. RV stated to W3 that an unknown aide hurt RV's hand. W7 provided care at 5:30 A.M. on the 7th, but did not provide nay transfers; denies observing any injury. The facility investigation established the injury occurred within 6 hours of being observed. No staff reported an injury. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +CO11054,385275,NF,2/15/2011,,3,1500,Substantiated,Substantiated,Neglect +OR0000707000,385275,NF,8/12/2011,Evidence and interviews indicated facility failure to provide timely notification to Resident #1's family when Resident #1 experienced a change in medical condition requiring hospital treatment.,2,0,Not Substantiated,Substantiated, +OR0000691800,385275,NF,6/1/2011,Evidence and interviews substantiated facility failure to comprehensively assess and respond to Resident #1's marked edema requiring hospitalization. Federal penalty recommended relevant portions of the complaint report are attached.,3,2500,Substantiated,Substantiated,Neglect +MM118602,385275,NF,11/24/2011,Evidence and interviews indicated RP2 (licensed nurse) treated Resident #1 disrespectfully by removing a paper item from Resident #1's possession against Resident #1's consent. Resident #1 sustained a paper cut on her/his finger as a result of the incident.,2,0,Not Substantiated,Substantiated, +MM129310,385275,NF,1/6/2012,Resident #1 had a history of aggressive behavior toward other residents including entering other resident rooms and seeking fluids. From December 2011 through January 2012 Resident #1 had eight documented physical altercations with other residents. Resident #1 sustained a documented injury as a result resident-to-resident behaviors as did Resident #3 who complained of right ear and jaw discomfort.,2,,Substantiated,Substantiated,Neglect +MM129759,385275,NF,4/5/2012,Evidence and interviews indicated facility failure to provide a safe environment for residents. Residents were involved in resident to resident altercations with residents sustaining injury.,2,300,Substantiated,Substantiated,Neglect +MM120352,385275,NF,6/2/2012,"Nursing notes for Resident #1 indicated she/he required one-on-one monitoring care for the safety of Resident #1 and other residents. On 05/26/2012 Resident #1 ran over another residents feet with a wheelchair. Resident #1 back-up and pushed the wheelchair into the resident's feet. On 06/02/2012 Resident #1 rolled over Resident #2's foot then backed-up and kicked Resident #2 in the leg. Resident #1 was receiving one on one monitoring on 05/31/2012 and 06/03/2012, however Resident #1 went into other residents rooms and voided on their bibles on these dates.",2,0,Substantiated,Substantiated,Neglect +MM132763,385275,NF,12/19/2012,"Evidence and interviews indicated RP2 (staff) argued with Resident #1 in December 2012, during that argument RP2 called Resident #1 a ""brat.""",2,0,Not Substantiated,Substantiated, +TM121460,385275,NF,10/26/2012,Evidence and interviews indicated facility failure to protect Resident #1 from RP2_x001A_s threats of harm. The facility's failure to protect Resident #1 from RP2_x001A_s threats of physical harm constitutes mental and emotional abuse.,2,0,Substantiated,Substantiated,Verbal/Mental abuse +MM133728,385275,NF,7/6/2013,"Evidence and interviews indicated facility failure to ensure RP2 (CNA) provided Resident #1 care assistance as care-planned related to implementing adequate behavior interventions during an incident on July 6, 2013.",2,,Not Substantiated,Substantiated, +MM134373,385275,NF,9/7/2013,"Evidence and interviews indicated facility failure to adequately address Resident #1_x001A_s increased behaviors and ensure a safe environment for residents resulting in a resident to resident altercation where Resident #2 sustained injury are violations of resident rights, are considered neglect of care and constitute abuse.",2,250,Substantiated,Substantiated,Neglect +MM134790,385275,NF,10/18/2013,"Facility documentation indicated Resident #2 wandered into Resident #1_x001A_s room with Resident #1 kicking Resident #2. Resident #1 had a history of physical aggression toward other residents. Resident #2_x001A_s outdated 04/02/2010 care plan indicated Resident #2 had, _x001A__x001A_a tendency to wander hallways. She/he may become aggressive if pushed or argued with_x001A__x001A_ + +The facility failure to adequately address resident behaviors and care plan with interventions resulting in a resident-to-resident altercation placed residents at risk of serious harm.",3,500,Not Substantiated,Substantiated, +MM135119,385275,NF,11/16/2013,"Facility documentation indicated Resident #1 had four documented incidents of aggression toward other residents since 09/07/2013. Facility documentation and witness interviews indicated Resident #1 tipped Resident #2_x001A_s wheelchair over on 11/16/2013, causing Resident #2 to fall on the floor hitting her/his head. Facility staff observed Resident #2 sustained a right elbow skin tear from the fall. + + + +The facility failure to adequately address Resident #1_x001A_s behaviors and care plan with interventions resulting in Resident #2 sustaining a fall with injury are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,Substantiated,Substantiated,Neglect +DA164252,385275,NF,1/10/2016,"Evidence and interviews indicated facility failure to assure Resident #1's right to be treated with consideration, respect, and dignity. On or about 1/10/2016 RP2 (CNA) was picking up trays in Resident #1's room and Resident #1 began calling RP2 names. RP2 responded to Resident #1 by calling Resident #1 names. RP2 reported the incident to staff, was suspended during an internal investigation and reassigned to a different area of the facility to minimize contact with Resident #1.",2,,Not Substantiated,Substantiated, +OR0000808202,38A001,NF,1/29/2013,"Resident 1 was admitted 2006 with multiple diagnoses. Resident's 10/13/2012 care plan indicated resident's responsible party was to be notified at anytime of any resident change of condition. On 1/26/2013 staff found bruising to the resident's thumb and finger, but failed to immediately notify the responsible party. This failure represents an Oregon Administrative Rule violation. Relevant portions of the survey are attached. Enforcement action was proposed.",2,0,Not Substantiated,Substantiated, +BC147289,38A001,NF,5/26/2014,"RP2 was attempting to change RV's brief as RV was objecting. RP2 admitted being in a rush, moving fast, attempting to reach RV's arm and ""brushed"" across RV's arm. RP2 and W1 disagree as to RP2 slapping RV's arm. RV did not sustain any mark or other sign of injury; no noted distress. RP2 should have backed off RV's care and or garnered assistance and or direction from the licensed nurse. RP2 failed to provide RV with all due respect; failed to honor RV's choice of no care. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +HB134831,38A026,NF,10/24/2013,"RP2 was in RV's room, but was called away by other staff for approximately 5 minutes. RV slid out of the wheel chair and sustained an abrasion to RV's back. RV's care plan directs staff to supervise RV when RV is up in the wheel chair in his/her room. RP2 was unaware of RV's care plan to not leave RV unsupervised. RP2 received a warning and further intruction. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +HB146063,38A026,NF,2/12/2014,"RV1 and RV2 have cognitive impairment and known behaviors. RV1 pushed RV2 when RV2 continued to follow RV1 around per staff report, RV2 fell and no known immediate signs of injury were identified; a bruised hip appeared 3 days later on 2/10/2014. Staff were aware that RV2's behaviors have increased and that RV1 dislikes other residents in RV1's personal space. RV1's care plan was adjusted to redirect other resident from RV1. RV2's medication was adjusted and staff were attempting to find the triggers for RV2's increased behaviors. On 2/18, 2014 another altercation occurred between RV1 and RV2. The event would have been prevented had staff timely followed RV1's care plan to redirect other residents (RV2) away from RV1. RV2 was pushed to the ground again, but did not sustain injury. RV2 was at risk for great potential harm. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000878600,38A026,NF,2/18/2014,"Resident 1 was admitted September 2009 with multiple diagnoses including dementia, fracture and osteoporosis. Resident care plan for transfer included use of two people for constant supervision with physical assist with Hoyer lift. On 2/15/2014 Staff 7 completed a Hoyer transfer without a second person. Staff 6 that the resident's left leg appeared different after the transfer. Staff 7 denied any problem with the transfer but heard a sound when positioning resident's leg on pillow. An x-ray confirmed a fracture of the leg, but given resident's history of osteoporosis the exact circumstance surrounding the fracture remains unknown. The facility failed to ensure resident's two person care plan was followed. Staff 7 received counseling in always follow the care plan relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BA117220,38A028,NF,6/9/2011,"RV1 displayed prior inappropriate sexual behaviors with staff; touching staff's behinds, attempting to kiss staff, etc. RV1' care plan did not address the behaviors with staff or interventions for possibly touching other residents. RV1's care plan was adjusted following the 6/9/11 incident; staff observed RV1 grab RV2 on 6/8/11 as RV2 was walking by RV1. .",2,0,Not Substantiated,Substantiated, +BA118116,38A028,NF,8/28/2011,"RP2 was a fairly new CNA and a new staff member to the facility. RP2 was given a fairly heavy resident load during a time when many residents exhibit sun downer symptoms and the residents are more needy. RP2 failed to provide care as care planned, i.e.. Not checking for incontinence or repositioning RV every two hours from 2:15 until 6:15 P.M. RP2 reported RV was dry and clean at 2:15 P.M. RV sustained very minor harm; red /excoriated skin which resolved by 9/4/11. The facility has since added additional staff.",2,0,Substantiated,Substantiated,Neglect +CO13074,38A028,NF,5/20/2013,"Repeat risk for harm regarding resident smoking material and failure to use designated smoking areas. On May 14, 2013 surveyors found cigarette butts in Resident 3_x001A_s room trash can. On May 15, 2013 Resident 3 was observed smoking outside in a non-designated smoking area, pinching of fire ash from cigarettes and placing the butts back into a pack of cigarettes in his/her left shirt pocket. Resident 3 was interviewed; and reported he/she would place the cigarette butts in his/her room trash can; and had been doing this for years. + + + +On May 15, 2013 it was determined that staff failed to monitor safe resident disposal of cigarette butts after finding two cigarette butts in Resident 3_x001A_s trash can despite surveyor and State Fire Marshal informing the facility management of their May 14, 2013 findings. Facility management failure to protect this resident and other facility residents from danger has been unsuccessful and surveyors informed the facility of Immediate Jeopardy situation on May 15, 2013.",3,3500,Not Substantiated,Substantiated,Neglect +BA133432,38A028,NF,6/6/2013,"RV was unable to give very much information, but did deny anyone telling RV to ""shut up. W1, RP2 and RP3 give conflicting accounts of what occurred when RP2 and RP3 were in RV's room and W1 listed outside the door. RP2 did say ""fatty fat"" roll over here with the resident laughing and joking. RP2's inappropriate comments could be misinterpreted by a resident, staff or family. RP2 was cautioned to monitor his/her conversation. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BA135325,38A028,NF,2/22/2013,RV denies being in pain and reports he/she does not track appointments. W1 reported RV's appointments were canceled without knowing why. RV missed a 1/31/2013 and a 2/20/2013 appointment due to inability to provide a two person transfer at the a appointment and scheduling with physical therapy. RV's 2/21/2013 appointment was missed due to an oversight and rescheduled for 2/22/2013. RV did not sustain known harm. The one missed appointment violated Oregon Administrative Rule.,2,,Not Substantiated,Substantiated, +BA135273A,38A028,NF,10/6/2013,Per resident and witness interview RP2 failed to provide adequate incontinence cared to multiple residents. RV6 reported waiting over an hour one time. W2 emailed W3 and W4 regarding lack of care for various residents on multiple days. The facility failed to ensure residents received adequate incontinence care. Residents were placed at risk for harm constituting neglect of care. Oregon Administrative Rule violation occurred.,3,1200,Substantiated,Substantiated,Neglect +BA135273B,38A028,NF,10/6/2013,"Per resident and multiple witnesses RP2 failed to follow resident care plan for repositioning of the resident. While RP2 received additional training, RP2 did not provide adequate care and services resulting in potential resident harm due to continued skin pressure. Residents were not only at risk for skin breakdown, but not repositioning a resident incapable of repositioning themselves would be an uncomfortable situation as perceived by a reasonable person. The facility failed to ensure adequate resident care constituting neglect of care and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +BA135273C,38A028,NF,10/6/2013,"RP2 failed to follow RV6's care plan for transfer and instead used a sit to stand lift. RV6 reported telling RP2 to stop ""jerking"" RV as it startled RV6. RV6 reported RP2 bumped RV's leg with the lift. RV6 reported it was not only RP2, but other staff, too who ""jerked"" RV around. The facility failed to ensure appropriate transfer for RV6 resulting in skin injury; Progress note of 10/21/2013 indicating a bruised shin as it was bumped by the lift. The facility failure resulted in actual injury and potential skin harm. This failure constitutes neglect of care and abuse. An Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +BA135273D,38A028,NF,10/6/2013,"RV8 and witnesses reported RP2 is rough with care. W3 reported RP2 did not ""understand"" how to get RV8 out of bed or keep RV in bed. W2 reported emailing W3, but problems persisted. RP2 gave varied verbal and written statements concerning RV8's care. The facility failed to provide adequate supervision and care to ensure RV8 was provided appropriate care resulting in neglect of care, potential for moderate harm and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +BA135273F,38A028,NF,10/6/2013,"RP2 failed to provide RV5 with adequate catheter care resulting in RV complaining of pain and laying in urine soaked garments. W2 reported e-mailing W3 with concerns regarding RP2's care of residents, but the problems persisted. W2 reported sending e-mails on 10/19/2013 and 11/11/2013. W3 denied knowing the resident went an entire shift without care. RP2 reported maybe forgetting at times, but now finding a ""system"" that worked. The facility failure to ensure adequate care and services regarding RV5's catheter care constitutes neglect and abuse.",2,,Substantiated,Substantiated,Neglect +BA135273E,38A028,NF,10/6/2013,RP2 failed to feed RV3 breakfast and removed the food tray without assisting RV to eat. RP2 reported the event occurred in the dining room. Witnesses reported their observation to W3. Any staff observing such an occurrence should have immediately reported the event to the charge nurse or administration and RV should have received immediate feeding assistance. RV3 had open wounds and proper nutrition would have been required for wound healing. The facility neglect of care placed RV at risk for further harm and constitutes abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +BA146130,38A028,NF,2/16/2014,"On or about 02/16/2014 RP2 failed to provide adequate incontinence care for RV1, RV2, RV3, RV4 and RV5. All RVs were left in urine soaked incontinence products and or bed linens. Additionally W6 reported finding dried feces on RV1 and ""foul green/yellow discharged caked to the catheter and genital area"" of RV3. RP2's failure to provide incontinence care and linen changes constitutes a serious loss dignity for RV5, as well as, a great risk for skin breakdown and or UTIs. RP2's actions constitutes abuse by neglect. The facility immediately responded to staff concerns regarding RP2. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Neglect +CO14219,38A028,NF,8/28/2014,"Based on observation, interview and record review, it was determined the facility failed to re-evaluate and treat episodes of pain for Resident 5 reviewed for hospice. Resident 5 was admitted to the facility September 2013 with multiple diagnoses and was receiving hospice care at time of the survey. During the resident interview on 8/25/2014 the resident stated she/he was experiencing violent leg spasms that caused pain and there were times it took up to an hour and ten minutes to receive medication; this was not acceptable to Resident 5. On 8/27/2014 staff provided ADL care within 3 to 5 minutes of Resident 5 receiving pain medication; time was insufficient for the medication to become effective. The resident experienced pain throughout his/her care on 8/27/2014. Additionally, staff failed to evaluate the effectiveness of resident_x001A_s routine pain medications. + + + +Resident 20 was admitted to the facility August 2014 with multiple diagnoses and use of a retention catheter. Based on observation, interview and record review, the facility failed to develop a temporary plan of care for use of the retention catheter placing this resident at risk for unmet needs.",3,1500,Substantiated,Substantiated,Neglect +OR0000903300,38A028,NF,6/23/2014,"Resident 1 was admitted November 2013 with multiple diagnoses. On May 23, 2014 Resident 1 bumped her/his leg getting into the whirlpool tub while starting to sit down and the whirlpool chair slid back on the tracks. Staff 10 could not recall for sure if the chair was locked, but reported catching the resident without observing the resident hit anything. Resident 1 reported his/her knee went down _x001A_full force_x001A_ onto the rail. Staff 10 stated other staff having had a problem with the chair falling off the tub rails. Staff 8 and 13 reported the chair had fallen off the tracks before. Staff 13 stated he/she had been told it was fixed multiple times, yet Staff 4 stated no one had reported a problem before. The facility failed to thoroughly investigate Resident 1_x001A_s fall and the reported problems with the chair. Resident 1 was sent for evaluation and treatment on separate occasions; and ultimately received a diagnosis of a distal left femur fracture. Resident 1 became non weight bearing and sustained considerable pain before the fracture was diagnosed. The facility failure to provide necessary care and services resulting in Resident 1_x001A_s injury and continued pain constitutes abuse. Relevant portions of the survey are attached. Oregon Administrative Rule violations occurred.",3,1500,Substantiated,Substantiated,Neglect +BA159889,38A028,NF,11/1/2014,"The facility failed to ensure RV's compression socks were available and or offered to RV to wear. RV's physician ordered RV to wear the socks. W7(a medical professional) stated he/she was ""leaning towards"" RV's death was due to a heart attack; not an embolism. W7 stated it (reference to RV's passing) was not all because of compression socks. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BH105607,38E018,NF,10/26/2010,"The facility had some history of medication thefts, but the facility had increased efforts to prevent theft. Staff observed RV's pain patch in place at 2:00 P.M. and it was missing by 3:45 P.M. RV did not sustain notable effects from the missing patch. The investigation failed to reveal who took RV's pain patch. The facility failed to ensure a safe environment for RV.",0,0,Not Substantiated,Substantiated, +CO11104,38E018,NF,5/31/2011,Life safety code non-compliance on revisit as outlined in the 7/20/2011 (2567) revisit survey.,0,0,Not Substantiated,Substantiated, +BH117429,38E018,NF,7/9/2011,"RV has memory loss and is unable to give relevant information. A complaint was made to the facility that RP2 had an attitude toward RV and said inappropriate things. RP2 acknowledged he/she may have been abrupt and probably did tell RV ""be quiet and eat."" RV has no injuries. RP2 failed to treat RV with all due respect. RP2 did not have prior disciplinary action of similar nature. RP2 received counseling regarding his/her behavior/attitude.",2,0,Not Substantiated,Substantiated, +BH105733,38E018,NF,11/27/2010,"RV1 and RV2's pain patches went missing between 1:30 P.M. and 4:00 P.M. Staff checked resident clothing, floor, chairs and laundry without finding the patches. 17 CNAs, nurses, housekeepers, health agency, resident and families were available to RV1 and RV2. no suspects were found. RV1 and RV2 did not sustain any notable harm and the patches were replaced. There is LEA involvement and resident patches are checked every shift.",2,0,Substantiated,Substantiated,Financial abuse +BH129284A,38E018,NF,2/1/2012,"RV1 was requesting coffee and RP2 purportedly was encouraging RV to drink water. There was some delay in getting RV's coffee as there were not cups in the area where RV was sitting. RV did receive coffee later on. RP2 acknowledged he/she should have ""just got the coffee"". The facility failed to ensure RV's right to choice was honored in a timely manner. This failure resulted in an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +BH129284C,38E018,NF,2/1/2012,RV3 sustained a bruise to his/her eye after RP3 placed RV3 to close to the bed edge and RV3 rolled into a side table. RP3 denies ever having a similar event occur. RV3 has sustained other bruises of unknown origin. On 2/18/2012 RV3's care plan was adjusted for further safety. The facility failed to ensure a safe environment resulting in a violation of the Oregon Administrative Rule.,2,0,Not Substantiated,Substantiated, +BH129367,38E018,NF,2/10/2012,"RP2 and RP3 failed to follow standard practice in dispensing medication to residents in a nursing facility. RP2 and RP3 worked together either pouring medication and or giving medication poured by each other. RP2 and RP3 signed the MAR as medication being given when it was not given. RP2 and RP3 _x001A_flagged_x001A_ residents to alert the next shift that medication needed to be given. Not all residents received medication as ordered and or in a timely manner. RP4 failed to make sure all CMAs were called when the originally scheduled CMA called in to not report to work. RP2 had not passed medication at this facility and was not familiar with the medication cart, etc. The facility failed to ensure all staff were properly in-serviced regarding the medication cart and medication pass for the facility. The facility failed to ensure all residents received their medications or if they received medication it was in a timely manner. While there were no known negative resident outcomes, residents were placed at risk for harm. The facility failure to ensure a safe medication system involving multiple residents represents a Oregon Administrative Rule violation.",2,350,Inconclusive,Substantiated, +BH129340B,38E018,NF,2/21/2012,"Facility staff failed to promptly assess or treat RV when bruising was discovered on 2/21/2012. The investigation was not begun until 2/23/2012. Staff failed to promptly report RV's bruising, considered a change of condition, to RV's family. RV was not care planned for a ""Sara lift"". The facility failure is an Oregon Administrative Rule violation.",2,0,Inconclusive,Substantiated, +BH132889,38E018,NF,4/6/2013,"W2 reported RP2 used a raised voice telling RV ""you are not supposed to push others. You are a parent of three, how could you do something like that."" W4 reported RP2 moving behind RV, grabbing RV's right arm and twist it up. W1 reported RV complained of some shoulder pain, but it was opposite of the arm reported as being twisted. RP2 admitted talking loudly and ""gently"" holding RV's hand, but denies ""twisting"" RV's arm. W5 reported RP2 grabbed RV's arm "" real hard"". Reviewer notes conflicting evidence provided by witnesses and RP2. evidence does support RP2 failure to treat RV with all due respect when RP2 raised his/her voice. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000842100,38E018,NF,7/30/2013,"Based on interview and record review it was determined the facility failed to assess and care plan negative statements related to death and possible self harm; and respond timely to a suicide attempt by Resident 1. Resident 1 had a past history of a suicide attempt. Staff observed a red ring around the resident's neck and the resident reported attempted suicide. Prior to finding the resident with evidence of self harm the resident was observed with the call light cord about his/her neck, exhibited increased agitation/behaviors and made statements about not wanting to live anymore. The facility failed to provide necessary care and services related to a suicide attempt resulting in harm and which constitutes abuse. An Oregon Administrative Rule violation occurred.",3,1500,Substantiated,Substantiated,Neglect +OR0000898700,38E018,NF,5/22/2014,Resident 1 was admitted 2013 with diagnoses including dementia and diabetes. The resident was re-admitted on 4/24/2014 following surgery for a fracture. The resident returned with orders for brace use at all times on the right leg. On 4/25/14 facility staff contacted the hospital regarding the orders for resident's brace without notifying the physician or providing follow up regarding the availability of the brace. The resident record indicates the brace was ordered 5/2/2014; following the original orders or 4/24/2014. A physician progress note of 5/8/2014 documented failure to use the brace despite strict instructions. The resident's physician applied a brace to resident's knee with an order to keep the immobilizer in place at all times. The facility failed to follow all physician orders resulting in the resident at extreme risk for harm. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +OR0000898701,38E018,NF,5/22/2014,"Resident 1 was admitted 2013 with diagnoses including dementia and diabetes. On 4/19/14 resident complained of pain, an x-ray was ordered and the resident was sent to the hospital with a fracture. W1 reported facility failure to notify W1 of resident surgery. The facility was not responsible to notify resident's possible party of resident surgery as the resident was already in the hospital at the time of the decision.",0,,Not Substantiated,Substantiated, +OR0000910700,38E018,NF,7/23/2014,"Resident 2 was admitted 2014 with multiple diagnoses. The facility failed to assess resident's changing condition, assess resident edema with changes to the resident's leg, failed to notify the physician in a timely manner and failed to arrange appropriate transport to the hospital when the resident was in ""excruciating pain/ omitting/ low BP "". The resident was unresponsive and likely in ""septic shock"" on hospital arrival. Staff reported it was not facility protocol to track resident edema. Staff miscommunicated resulting in the resident going to the hospital by taxi. Facility failures resulted min inadequate care and services related to a resident's changing condition. In record review it was also determined the facility failed to update the resident's care plan regarding fall prevention. Relevant portions of the survey are attached. A civil penalty was proposed. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Neglect +BH149573,38E018,NF,12/6/2014,"RP2 signed out narcotics for RV1, 2, 3, 4, 5 and 6. RV1 through 6 receive regularly scheduled narcotics; not PRNs that require documentation for the reason they are receiving the medication and the noted effect of the medication. W3 found multiple white pills on the floor of another resident's room other than any of the rooms for RV1 through 6. RP2 was the only person with access to the medication cart at the time the medications were signed out and the time the pills were discovered in another resident's room. None of the RV's were able to give information. The facility investigation did not find RV1 through 6 showing any signs of increased pain. The preponderance of evidence supports RP2 diverting RV1 through 6's narcotic medication constituting abuse through theft of resident medication. Oregon Administrative Rule violations occurred.",3,,Substantiated,Substantiated,Financial abuse +OR0000958800,38E018,NF,3/26/2015,"Resident 49 was admitted to the facility in 2011 with diagnoses including dementia. The resident's 2/27/15 MDS and associated CAAs identified the resident's fall risk. The resident sustained fall from his/her wheel chair, but the post fall investigation of 3/13/2015 failed to include evidence as to whether or not RV's wheel chair had foot pedals in place. Staff 5 stated transporting the resident and the foot rests were in place at the time of the fall. The facility failed to thoroughly investigate resident's fall to ensure the resident's care plan interventions were in place. On 3/20/2015 the resident was being transported into the building and was at risk for another fall as the resident was lifting his/her feet. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000958801,38E018,NF,3/26/2015,Resident 49 was admitted to the facility in 2011 with diagnoses including dementia. Record review and interview noted resident lethargy on 1/12/15 at 6:23 P.M. and sustained a seizure lasting 15 seconds. Staff failed to notify W1 (resident's family). This placed resident's responsible party at increased risk for limited involvement in treatment and care decision-making processes. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +BH150363,38E018,NF,2/21/2015,RV2 bumped RV1's chair and attempted to take RV1's salad; RV1 attempted to push RV2 away and scratched RV2. Staff failed to monitor and intervene as RV2 wandered resulting in the altercation. The altercation between RV1 and RV2 was preventable. The facility failed to ensure all staff knew of RV2's care plan and the care plan was enforced. Failure to provide a safe environment resulting in resident harm constitutes abuse. Oregon Administrative Rule violation occurred.,2,,Substantiated,Substantiated,Neglect +BH153368,38E018,NF,5/13/2015,RV received more than one Exelon patch at a time. RV was at risk for harm. The facility failed to have an adequate medication administration system in place to avoid duplicate patches. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +BH147394,38E018,NF,6/12/2014,RV1 wandered into RV2's room; and emerged with a bloody nose and red lip. Staff provided assessment and new safety interventions including a stop sign at RV2's door. While RV1's care plan focused on RV1's behavior it failed to provide varied interventions prior to the event even though RV1 was know to staff to wander aimlessly in and out of resident rooms. RV2's care plan dated 1/22/2014 was to anticipate RV2's needs and not up dated relating to possible resident to resident altercation. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +BH164600,38E018,NF,1/28/2016,"Per witness interview and record review RV2 has a history of aggressive behaviors, grabbing other residents and throwing things. The incident report dated 1/28/2016 involving RV2 grabbing and slapping RV1 indicates RV2's involvement in similar events on 4/9 and 13/2015; and 5/13/2015; and 9/21/2015. The incident report also speaks to RV2's poor impulse control and wandering. The facility failed to provide adequate intervention regarding RV2's aggressive behavior toward other residents resulting in resident pain and suffering, as well as, further risk of harm to all residents coming in contact with RP2. The facility failure to provide a safe environment constitutes abuse. Oregon Administrative Rule violations occurred.",2,300,Substantiated,Substantiated,Neglect +BH164606,38E018,NF,1/28/2016,RV2 has a history of inappropriate sexual behavior toward other residents as indicated in RV2's progress notes including dates of 12/7/ 9/15/19 and 20/2015. On 1/28/2016 W2 observed RV2 touching RV1's breast while RV2 exposed RV2's genitals. The facility failed to provide a safe environment for all residents; specifically failed to prevent RV2 from inappropriately touching RV1 and exposing RV1 to RV2's genitals. The facility failure to provide a safe environment for RV1 and other residents constitutes abuse. Oregon Administrative Rue violations occurred.,2,250,Substantiated,Substantiated,Neglect +OR0000769200,38E024,NF,6/26/2012,Resident 1 was admitted 3/19/2012 with specific medication orders. In April 2012 Resident 1's MAR noted that resident received an extra dose of medication not ordered by his/her physician. There is no evidence the resident sustain a negative effect. Relevant portions of the survey are attached. Enforcement action was proposed. An Oregon Administrative Rule was violated.,2,0,Not Substantiated,Substantiated, +ST120401,38E024,NF,6/28/2012,"RV had known behaviors; attacking staff and other residents. W1 and W3 addressed RV's behaviors/needs with a plan for either W1 or W3 to stay with RV during peak agitation time. W2 reported attempting to speak with W3 about W3's leaving RV alone, but failed to. W2 reported RV became agitated, chased a care giver, punched W2 and hit/pushed RV2. The facility failed to ensure RV1's care plan was followed. The facility failure represents an Oregon a Administrative Rule violation.",2,0,Not Substantiated,Substantiated, +OR0000775700,38E024,NF,7/31/2012,Resident 1 was admitted 7/20/2012 with multiple diagnoses. Resident's care plan identified a high fall risk with noted interventions including close supervision. Resident's forgetfulness and confusion were identified. Resident made it out of a locked door down to the facility parking lot where he/she sustained an unwitnessed fall with injury. The facility failed to adequately supervise Resident 1 resulting in his/her injury. Relevant portions of the survey are attached. Enforcement action was proposed. The facility failure is an Oregon Administrative Rule violation.,2,0,Not Substantiated,Substantiated, +ST121809,38E024,NF,12/5/2012,"The facility failed to provide a safe environment. RV1 was known to be aggressive with staff and residents. Staff reported RV1's behaviors were escalating the night before RV1 physically accosted RV5 and RV 6 on 12/5/2012. The facility failed to ensure RV1 received physician ordered behavior medication at 6:00 A.M. on 12/7 & 10/2012. RV1 physically accosted RV2, RV3 and RV4 on 12/10/2012. Additionally, RV1's care plan was not thoroughly completed and or staff informed regarding RV1's behaviors and interventions to those behaviors resulting in actual minor harm with a potential for serious harm to multiple residents over a five day period of time. This facility failure constitutes abuse and Oregon Administrative Rule violation.",2,350,Substantiated,Substantiated,Neglect +ST121964,38E024,NF,12/10/2012,"Witnesses give varied accounts as to RP2's interactions with RV1 and RV2. neither RV is able to give relevant information due to cognitive impairment. RP2 acknowledge pushing RV1's wheel chair from the table to await assistance to reposition RV1; not in anger or in roughness. RP2 acknowledge being upset when called from his/her break to toilet RV2, but does not recall cursing, but did tell RV2 that RV had just gone to the toilet as redirection; not due to being agitated with RV. RP2 is reminded that residents may perceive RP2's agitation as being directed at them even if RP2 did not intend this. RP2 received further counseling by the facility. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +ST133387,38E024,NF,5/31/2013,"RV was given hot coffee; spilled the coffee; and sustained burns to RV's thighs resulting in blistered and open skin. Witness interview indicated RV was shaky, at risk to spill and coffee should have been ""cooled"". The facility failed to provide appropriate assessment and care planning; sufficient supervision of RV; and clear direction for all staff providing hot coffee to RV. The facility failure resulted in an unsafe environment with moderate harm to RV which constitutes abuse by neglect. An Oregon Administrative Rule violation occurred.",3,400,Substantiated,Substantiated,Neglect +ST133825,38E024,NF,7/15/2013,"RV is an elopement risk and care planned for redirection when near exits. Staff failed to adequately monitor RV and RV was found in the facility parking lot. This was the first elopement for RV. RV was unharmed, but at risk for harm. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +ST134854,38E024,NF,10/24/2013,RV a known elopement risk exited the facility through a door with a disabled alarm into the facility courtyard. RV then exited the courtyard through an unlocked gate. Staff failed to follow RV's care plan to watch RV and redirect RV from exit doors. RV was found by a neighbor alongside a busy road way. Failure to follow RV's care plan and provide a secure environment placed RV at great risk for harm. The facility neglect of care constitutes abuse. Oregon Administrative Rules were violated.,2,300,Substantiated,Substantiated,Neglect +ST146394,38E024,NF,3/1/2014,"RP2 spoke loudly to RV and ""harsh"" per W4, W3 and RV. Staff had cleaned the ice machine and posted a sign telling residents to stay out of the ice machine due to infection control issues. RP2 admitted being loud and did apologize to RV. RP2 will no longer work with RV. Given evidence by a reliable W4 and RP2 self report, RP2 failed to treat RV with all due respect. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +ST146641,38E024,NF,4/7/2014,RP2 administered another resident's medication to RV without notable effect. RP3 failed to administer RV's medication resulting in some anxiety. RP2 had a prior medication error and reported feeling fatigued; the error occurred during the second shift of a double shift. RP3 admitted to prior medication errors and reported not getting in trouble. The facility failed to properly supervise and ensure staff with prior medication errors appropriately dispense medication to RV on two occasions. RV sustained minor negative outcome. RV and other residents were at risk for further harm due to repeated medication errors not sufficiently addressed by facility administration. Oregon Administrative Rule violations occurred.,2,200,Not Substantiated,Substantiated, +ST150036,38E024,NF,1/25/2015,"W2 reported no staff observed the start of the incident between RV1 and RV2. RV1 acknowledged pulling RV2's hair. RV2 reported RV1 sat beside RV2, RV2 was coughing, RV1 began yelling at RV2 and the grabbed RV2's pony tail scratching RV2's neck. W2 reported RV1 was combative with staff the Friday before this event; attempting to grab and bite staff. W2 reported similar RV1 behavior towards residents in August 2014. Not all staff were aware of RV1's behaviors and or the resident's preventive care plan dated 8/16/2014. The facility failed to ensure a safe environment resulting in minor harm which constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +CO15058,38E024,NF,2/26/2015,"Based on observation, interview and record review it was determined the facility failed to ensure the resident environment remained free of potential accident hazards related to smoking for 1 of 3 (#19) sampled residents reviewed for accidents. In addition, the facility failed to provide appropriate equipment and training to extinguish a possible fire caused by a smoking accident. Resident 19 experienced multiple burns related to smoking and continued at risk for serious injury or harm due to burns as indicated in the attached pages of the survey. + + + +Based on the facility_x001A_s Immediate Jeopardy in the area of resident safety, the established substandard quality of care and citations in the areas of Resident behavior and Facility Practice and Quality of Care it was determined the facility was not administered in a safe, effective and efficient manner. As a result, this placed all residents at risk for not receiving the necessary care and services to attain or maintain their highest practicable physical, mental and psychological well being as indicated in the attached pages of the survey.",4,3050,Substantiated,Substantiated,Neglect +ST150792,38E024,NF,2/12/2015,"The facility allowed private time between RV and W1 without clear indication RV was able to consent. The facility failed to ensure other residents in RV's room Resident Right's were protected. W1 wanted to stay in RV's room after other residents went to bed. W11 reported a complaint was made regarding W1 staying in RV's room, but the facility failed to address the concern. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000954100,38E024,NF,3/11/2015,"On 5/4/2015 Staff 3 inadvertently gave Resident 1 another resident's medication. Resident's blood pressure fell to 96/68, the resident was sent to the hospital and returned the same day. The facility failed to ensure a safe medication system was in place resulting in resident harm lasting less than 24 hours. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000967000,38E024,NF,5/4/2015,"Resident 1 was admitted in 2012 with multiple diagnoses. On 3/10/2015 resident was given blood pressure medication indicated for another resident, resident's blood pressure fell to 76/40 and the resident was transferred to the hospital. Staff 2 confirmed inadvertently giving Resident 1 the other resident's medication. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ST151393,38E024,NF,5/27/2015,"RV1 reported RV2 grabbed RV1's arm while both were seated in the dining room. RV1 reported RV2's yelling is worsening and RV2 gets violent. RV2 was unable to give relevant information. Witnesses believe RV2 has no intent, but just grabs out as being effected by RV's sight. W2 reported RV1 has been struck before and RV1's behaviors may be effecting other residents. The facility failed to assess and care plan RV1's behavior. The facility failure to address residents behaviors and provide timely appropriate interventions constitute neglect and abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +ST151647,38E024,NF,4/12/2015,RV1 became upset and struck RV2 as RV2 attempted to assist RV1. RV1 had exhibited similar behavior in the past. There were no staff in the dining room at the time of the event. RV1's care plan was updated after this third event. The facility failure to provide a safe environment resulting in the resident to resident physical altercation constitutes abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Neglect +OR0000972400,38E024,NF,5/26/2015,Resident 1 was admitted in 2012 with multiple diagnoses. W1 reported RV sustained multiple falls (4 to 7 in a week) and W1 requested assessment for a walker or to have someone with the resident. The resident sustained 17 falls from 4/29/2015 to 7/21/2015 with noted reassessment and care plan changes after each fall. Staff worked with the resident's choice to wear flip flops although this lended itself to increased unsteadiness. The resident was very independent and did not always ask for assistance. The facility did not fail to address Resident 1's falls. An expanded resident sample regarding Resident 2 and 3 did reveal concerns as found in the attached investigation report resulting in a TAG citation and proposed enforcement. Oregon Administrative Rule violation occurred.,2,,Not Substantiated,Substantiated, +OR0000901800,38E032,NF,6/10/2014,the facility failed to thoroughly investigate Resident 1's unexplained left upper arm bruising. Staff failed to note vital signs and or failed to document the appearance of bruises on the TAR. The ADL care plan was not updated until 3/17/2014. the resident complained of pain and the physician ordered an x-ray on 3/18/2014 with a finding of a fractured humerus. The facility failure placed the resident at risk for further harm. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +RD148289A,38E032,NF,8/10/2014,"RV1 and RV2 tend to seek each other's attention and interact in negative manner; apparently upsetting each other. There have been at least three occurrences between July 5th and August 14, 2014 without sufficient plan updates or adequate interventions. Neither RV was injured, but revs were upset. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +RD152306,38E032,NF,7/15/2015,Between 6/21/15 and 7/2/15 narcotic prescriptions for RV went missing. Evidence failed to point to a specific individual. RV did not sustain pain or discomfort. Staff caught the theft with in two week time period and provided intervention to prevent future thefts of medication. The theft of RV's medication constitutes abuse. Oregon Administrative Rule violations occurred.,2,,Substantiated,Substantiated,Financial abuse +OR0000991700,38E032,NF,8/12/2015,"The facility failed to provide minimum C.N.A. staffing per rule. Based on observation and record review, it was determined the facility failed to maintain minimum levels of C.N.As on five of 44 days. Relevant portions of the survey are attached. Enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BO165015,38E032,NF,2/27/2016,"The complainant voiced multiple concerns as identified in the investigation report. W3 reported observed RV's bed control wire wrapped around RV's wrist, observed RP2 ""rip"" the controller out of RV's hand and observed torn skin at the site, reported RV started screaming ""get out"" and reported observing RV punching RP2's chest. W3 reported ""blood all over"" and RP2 saying ""you're gonna take a shower"". W3 reported writing a statement regarding the incident, it was found torn up and W3 taped the statement together giving, gave the taped statement to W2 and wrote another statement after the shift. W1 reported interviewing W3 and W4, but not writing the interviews or reporting the incident as nothing to report. RV used hand signals to confirm the injury was caused by a person of the same sex as RP2. W4 confirmed observing RV's injury, finding the torn statement by W3 and went to W1 on 2/29/2016 with W4's opinion of what occurred. The facility administration failed to promptly and thoroughly investigate, document and report a resident injury. The preponderance of evidence supports RP2 provided rough care resulting in RV's very large skin tear to the left wrist/forearm. RP2's rough care constitutes abuse. Oregon Administrative rule violations occurred.",3,,Inconclusive,Substantiated,Neglect +JD116659,38E040,NF,12/10/2010,RP2 (CNA) placed her/his hand over Resident #1's mouth and told Resident #1 to shut up on 8/10/2010 and 12/10/2010. RP2 was providing care with an additional caregiver during both occurrences.,2,0,Substantiated,Substantiated,Verbal/Mental abuse +CO11118,38E040,NF,10/5/2011,,0,6500,Not Substantiated,Substantiated, +OR0000688102,38E075,NF,5/12/2011,"Staff #6 (licensed nurse) said she/he compiled signed skin treatment assessment documentation for Resident #5 from 4/12/2011 through 5/29/2011 from memory on 5/31/11. Staff #6 was not on duty for three of the dates (4/3011, 5/22/11 & 5/29/11) in which she/he made entries on a skin impairment record. Relevant portions of the survey report are attached.",2,0,Not Substantiated,Substantiated,Neglect +OR0000688103,38E075,NF,5/12/2011,"After falling on 5/10/2011, Resident #1 had complaints of right hip pain. Resident #1 was sent to the hospital for evaluation. Staff #6 reported she/he _x001A_might not_x001A_ have notified Resident #1's family regarding Resident #1's hospitalization.",2,0,Not Substantiated,Substantiated,Neglect +MV120507,38E075,NF,7/1/2012,Evidence and interviews indicated RP2 (CNA) improperly administered Resident #1 Lorazepam when Resident #1 asked for a dose of PRN (as needed) Oxycodone. There was no documented harmful outcome to Resident #1 as a result of RP2's medication administration error.,2,0,Not Substantiated,Substantiated, +OR0000779900,38E075,NF,8/24/2012,Evidence and interveiws indicated facility failure to ensure sufficient number of CNA's to meet the state mininum staffing requirements. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +MV121230,38E075,NF,10/3/2012,On 10/13/2012 RP3 (CNA) assisted Resident #1 with toileting using a bed pan. Resident #1 said she/he would use the call light to ask for assistance when she/he was done. RP2 (CNA) said she/he did not see Resident #1's call light on when she/he started shift. Evidence and interviews indicated Resident #1 was left on the bed pan unassisted for approximately an hour.,2,0,Substantiated,Substantiated,Neglect +MV146620,38E075,NF,3/6/2014,"Evidence and interviews indicated the facility failed to provide Resident #1 timely assessment, intervention and treatment for her/his burn resulting in the burn blistering and a delay in medical treatment. Evidence and interviews indicated the facility failed to provide Resident #1 timely assessment, intervention and treatment for her/his burn resulting in the burn blistering and a delay in medical treatment. These failures are considered violations of resident rights, considered neglect of care, and constitute abuse.",3,400,Substantiated,Substantiated,Neglect +MV153193,38E075,NF,10/15/2015,"Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 related to left-side upper chest bruising of unknown origin. Evidence and interviews indicated facility failure to adequately assess, intervene, and document Resident #1_x001A_s left-side upper chest bruising of unknown origin placing Resident #1 at risk of further injury. In addition, evidence and interviews indicated facility failure to adequately administer Resident #1_x001A_s medication orders for an injectable anti-psychotic medication resulting in Resident #1 not receiving a scheduled dose as ordered.",3,250,Not Substantiated,Substantiated, +OR0001035601,38E075,NF,12/4/2015,Evidence and interviews indicated facility failure to ensure complete and accurate medical records related to anti-hypertensive medication for Resident #2. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +MM164834B,38E113,NF,2/29/2016,"Evidence and interviews indicated facility failed to assure Resident #2's right receive care assistance with consideration, respect, and dignity when receiving care assistance from RP2 (CNA). RP2 said after leaving Resident #2's room she/he told witness #5 (CNA) RP2 was about to get fired because RP2 was going to _x001A_punch_x001A_ Resident #2 in the face. RP2 said she/he asked for help with assisting Resident #2 and left Resident #2's room making the statement outside of Resident #2's room; RP2 went on leave from work after the incident.",2,,Not Substantiated,Substantiated, +BC116843,38E126,NF,3/24/2011,"Evidence and interviews indicated RP2 (licensed nurse) failed to protect Resident #1's dignity when providing care assistance on March 24, 2011.",2,0,Not Substantiated,Substantiated, +BC117026,38E126,NF,4/12/2011,Evidence and interview indicted Resident #1's order for a mineral supplement was incorrectly transcribed onto her/his medication administration record (MAR) on 2/13/2011 and again on 4/12/2011. Resident #1 was administered a double dosage of the physician ordered mineral supplement from 2/3/2011 through 4/18/2011.,2,0,Not Substantiated,Substantiated, +BC116948,38E126,NF,5/4/2011,The facility failed to provide adequate care planning and ensure adequate behavior interventions were implemented to prevent RP2's rough handling of Resident #1 on 5/4/2011.,3,450,Substantiated,Substantiated,Neglect +CO11090,38E126,NF,7/1/2011,,0,1100,Not Substantiated,Substantiated, +OR0000717800,38E126,NF,9/28/2011,The facility failed to ensure timely nutritional interventions for Resident #8 who sustained a significant weight loss. Relevant portions of the complaint report investigation are attached.,3,450,Substantiated,Substantiated,Neglect +BC118715,38E126,NF,12/15/2011,Evidence and interviews indicated facility failure to protect Resident #1 from inappropriate sexual contact by Resident #2. The facility failed to ensure adequate behavioral interventions for residents resulting in Resident #1 and Resident #2 sustaining inappropriate sexual contact. The Facility_x001A_s failures are considered neglect of care and constitute sexual abuse.,2,300,Not Substantiated,Substantiated,Sexual abuse +OR0000722600,38E126,NF,10/24/2011,Evidence and interviews indicated facility failed to timely respond to Resident #1's change of condition. Relevant portions of the survey complaint are attached; federal penalty recommended.,4,4000,Substantiated,Substantiated,Neglect +BC117183,38E126,NF,5/31/2011,"RP2 (licensed nurse) diverted pain medication from resident_x001A_s narcotic cards and the facility E-Kits. RP2 took resident_x001A_s pain medications over a two month period beginning in April 2011 and ending with RP2_x001A_s dismissal from facility employment on June 1, 2011. RP2 also took an estimated $330 in PIF funds from facility residents.",3,1200,Substantiated,Substantiated,Financial abuse +BC129480,38E126,NF,3/9/2012,"Evidence and interviews indicated facility failure to adequately administer Resident #1's medication on 03/09/2012, 03/10/2012 and 03/11/2012.",3,400,Substantiated,Substantiated,Neglect +OR0000742900,38E126,NF,2/2/2012,Evidence and interviews indicated facility failure to provide a safe environment for residents resulting in a resident-to-resident altercation between Resident #1 and Resident #2. Resident #1 sustained injury requiring hospitalization. Relevant portions of the complaint report are attached.,3,1500,Substantiated,Substantiated,Neglect +OR0000746900,38E126,NF,2/28/2012,Evidence and interviews indicated the facility failed to provide adequate care and services in a timely manner for Resident #3 who experienced a change of condition. Without timely intervention Resident #3 continued to experience a decline in condition resulting in hospitalization. Relevant portions of the complaint report investigation are attached.,3,1500,Substantiated,Substantiated,Neglect +BC121436,38E126,NF,10/23/2012,Evidence and interviews indicated on 10/23/2012 RP2 (CNA in training) failed to ensure fall prevention interventions were in place as per Resident #1's care plan. Resident #1 had an un-witnessed fall from her/his bed and sustained abrasions to her/his right hand and right temple. RP2 received written counseling regarding the importance of following residents care plans.,2,0,Substantiated,Substantiated,Neglect +OR0000783600,38E126,NF,9/13/2012,Evidence and interviews indicated facility failure to provide Resident #1 adequate care and services related to falls. Relevant portions of the complaint report investigation are attached.,3,1500,Substantiated,Substantiated,Neglect +OR0000796200,38E126,NF,11/29/2012,Evidence and interviews indicated facility staff failed to ensure Resident #1's care planned pressure bed alarm was in place when Resident #1 had an unwitnessed fall on 11/27/2012. Resident #1_x001A_s 11/27/2012 fall reportedly a non-injury fall.,2,0,Not Substantiated,Substantiated, +OR0000797301,38E126,NF,12/7/2012,Evidence and interviews indicated facility failure to clarify a physician's order prior to administering Resident #1's anti-depressant medications. Evidence and interviews indicated facility failure to monitor Resident #1's sleep pattern to determine medication effectiveness when insomnia medications were changed for Resident #1. Facility failure placed Resident #1 at increased risk for potential adverse medication reactions and sleeplessness. Relevant portions of the complaint report survey are attached.,2,0,Not Substantiated,Substantiated, +OR0000797304,38E126,NF,12/7/2012,Evidence and interviews indicated facility failure to operationalize their policy and procedures regarding a thorough investigation for Resident #1 who sustained bruising of unknown origin. The facility failure placed Resident #1 at risk for potential further injury. Relevant portions of the complaint report investigation are attached.,2,0,Not Substantiated,Substantiated, +BC121881,38E126,NF,11/11/2012,Evidence and interviews indicated facility failure to ensure a safe environment for Resident #1 and Resident #2 on 11/11/12 resulting in Resident #1 and Resident #2 getting into an altercation with both residents sustaining hitting.,2,0,Substantiated,Substantiated,Neglect +BC133454,38E126,NF,6/6/2013,"Evidence and interviews indicated facility failure to properly readmit Resident #1 to the facility between June 5, 2013 and June 7, 2013. The facility failure to properly readmit Resident #1 is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,800,Substantiated,Substantiated,Neglect +OR0000828800,38E126,NF,5/8/2013,Evidence and interviews indicated facility failure to inform Resident #3's family of medication changes. This failure placed Resident #3 at risk for not having interested family able to participate in decisions regarding the residents' medical care. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +BC134903,38E126,NF,10/30/2013,"Facility documentation indicated Resident #1 had a history of combative behavior toward residents and two prior altercations with residents with minor injuries since July 2013. On October 30, 2013, facility staff observed Resident #2 to have blood on her/his face. Facility staff observed Resident #1 to have a small laceration and redness to her/his right knuckle. Resident #1 told facility staff she/he had, ""got her/him real good"" when facility staff asked Resident #1 why she/he hit Resident #2. The facility failure to adequately address Resident #1's behavior and ensure a safe environment for residents resulting in a resident to resident altercation where residents sustained injury are violations of resident rights, are considered neglect of care and constitute abuse.",2,600,Substantiated,Substantiated,Neglect +BC134904,38E126,NF,10/17/2013,"Resident #1 had a physician order for 5 mg or 10 mg of a narcotic pain medication every six hours. Evidence and interviews indicated RP2 (licensed nurse) failed to administer Resident #1's narcotic pain medication as ordered on 10/17/2013 when administering Resident #1 a 15 mg dose of narcotic pain medication. In addition, RP2 indicated she gave Resident #1 the medication one time in the morning (around 5:30 am) however RP2 documented that she/he administered Resident #1 the incorrect dose of narcotic pain medication at two different times on 10/17/2013.",2,,Not Substantiated,Substantiated, +OR0000887700,38E126,NF,4/2/2014,Evidence and interviews indicated facility failure to provide Resident #109 and Resident #125 a safe environment regarding safety and supervision. Resident #109 had four separate documented resident-to-resident altercations between 1/13/2014 and 3/14/2014. Resident #109 and Resident #125 were involved in an altercation on 4/2/2014. Staff #25 (licensed nurse) found both residents lying prone on the floor with copious amounts of blood from skin tears on Resident #109's left arm. Resident #125 was observed to have redness around her/his left eye and a bump on the back of her/his head. The Facility failure to ensure Resident #109 and Resident #125 received adequate supervision and safety resulting in both residents sustaining injuries requiring hospital evaluation is violations of resident rights are considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.,3,400,Substantiated,Substantiated,Neglect +BC147582,38E126,NF,6/18/2014,Evidence and interviews indicated facility failure to protect Resident #1 from the theft of cash. A facility self-report indicated Resident #1 reported the theft of approximately $200 on 6/26/2014.,3,,Not Substantiated,Substantiated,Financial abuse +BC149129,38E126,NF,11/3/2014,"Evidence and interviews indicated facility failure to provide a safe environment for Resident #1 when coordinating details regarding Resident #1's move (discharge) to another facility. Resident #1 moved (discharged) to another facility via taxi and if a staff member at the new facility had not seen Resident #1 getting out of the taxi when arriving at the facility, Resident #1 might have become lost.",2,,Not Substantiated,Substantiated, +BC150433B,38E126,NF,3/1/2015,Evidence and interviews indicated facility failure to protect Resident #1 from the loss of personal property (clothing).,2,,Not Substantiated,Substantiated, +OR0000930500,38E126,NF,10/30/2014,"Evidence and interviews indicated facility failure to adequately investigate resident altercations for Resident #1. This failure placed Resident #1 at risk for injuries from continued altercations. October 18, 2014 documentation for Resident #1 indicated she/he was involved in a resident altercation with Resident #8 on or about 10/18/2014. Resident #1 was found lying on her/his back in front of Resident #8_x001A_s bed with large amounts of blood on the floor next to Resident #1. In addition, evidence and interviews indicated facility failure to ensure a safe environment with Resident #1_x001A_s supervision and failure to update care plans related to resident altercations for Resident #1. The Facility failure to adequately investigate altercations, update care plans and ensure Resident #1 a safe environment, resulting in Resident #1 sustaining injury requiring hospital treatment is violation of resident rights are considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,500,Substantiated,Substantiated,Neglect +OR0000930501,38E126,NF,10/30/2014,Evidence and interviews indicated facility failure to notify Resident #1's responsible party regarding a resident to resident altercation and Resident #1's hospitalization. The facility failure to notify Resident #1's responsible party placed Resident #1 at risk for lack of involvement in the residents' care. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000932901,38E126,NF,11/12/2014,Evidence and interviews indicated facility failure to follow physician orders for Resident #2's insulin administration as a result Resident #2 was at risk for diabetic complications from not receiving the medication as ordered. Relevant portions of the complaint report investigation are attached.,2,,Not Substantiated,Substantiated, +OR0000932902,38E126,NF,11/12/2014,"Evidence and interviews indicated facility failure to ensure Resident #2_x001A_s physician was notified of Resident #2_x001A_s continued weight loss. August 18, 2014 documentation indicated Resident #2's weight was 107.2 pounds and 10/20/2014 documentation indicted Resident #2's weight was 89.4 pounds; a 17.6 pound weight loss. October 24, 2014 physician progress notes indicated Resident #2 had lost weight in the past two months and the physician requested follow-up on the weight loss. Witness #5 (physician) said the facility did not report Resident #2's weight loss between physician visits. The Facility failure to provide adequate care and services related to Resident #2's significant weight loss, resulting in Resident #2's undesirable weight loss, is violation of resident rights, considered neglect of care and constitutes abuse. Relevant portions of the complaint report investigation are attached.",3,400,Substantiated,Substantiated,Neglect +OR0000770900,38E156,NF,7/9/2012,"While Staff 2 had checked Resident 1 at 5:30, 6:00 and 6:15 A.M., staff failed to check and ensure the alarm was turned on the floor alarm mat. At 6:30 A.M. staff found Resident 1 on his/her knees at roommates bedside. Resident 1 was not injured. All staff received further in-service regarding the importance to check alarms at the beginning of their shift. The facility failure represents an Oregon Administrative Rule violation. Relevant portions of the survey are attached.",2,0,Not Substantiated,Substantiated, +CO13010,38E156,NF,1/28/2013,Intent to impose DPNA; survey 10/25/2012,0,0,Not Substantiated,Substantiated, +OR0000798600,38E156,NF,12/17/2012,"Resident 1 was admitted in 2010. Resident's care plan indicated use of an alarm floor mat at all times. Staff 2 assisted the resident to the commode, gave him/her the call light and left the room; not thinking to place the commode on the floor mat. The resident attempted a self transfer, fell and sustained bruising about his/her head. Relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +EN145658,38E156,NF,8/7/2012,"RV1 was without history of leaving the facility, but had a history of verbal threats to leave and take RV2 with them. On 8/7/2012 staff failed to man the ay room at all times when residents were present. RV1 and RV2 were found outside. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +CO11023,38E157,NF,1/21/2011,"Facility failure to ensure policy/procedure for identifying and preventing verbal abuse. Immediate jeopardy fire code hazards represented by electrical, equipment and various building hazards. L",3,10000,Not Substantiated,Substantiated, +OR0000659700,38E157,NF,1/7/2011,"Resident 1 was admitted with multiple diagnoses including a history of a CVA with left sided hemiplegia. Resident 1 was assessed as a high risk for falls with care plan interventions of a two-person transfer, use of a transfer pole and non skid foot wear. On 12/9/10 at 6:30 P.M. Resident fell during a one person assist by Staff 4. The internal investigation report found the transfer pole came loose and Resident 1 fell landing on top of Staff 4. Resident 1 was not injured. Staff 4 reported not using a gait belt or other staff to assist with the transfer. Staff 4 also reported not reading Resident 1's care plan prior to the transfer. Staff 4 received counseling and all facility transfer poles will be checked on a weekly basis. Staff will also pull on the transfer pole before each use. Relevant portions of the survey are attached. A plan of correction was submitted.",2,0,Not Substantiated,Substantiated, +BC121351,38E157,NF,10/14/2012,"RV approached RP2 and grabbed RP2's clothing while telling RP2 to quit ""singing"". RP2 grabbed RV's arm; and W3 stepped between RP2 and RV, while telling RP2 to leave. RP2 did not leave, but re-engaged with RV striking RV's arm/hand. RV sustained a bruised left upper arm. RP2's behaviors and actions constitute physical abuse. The facility failure represents an Oregon Administrative Rule violation.",2,0,Not Substantiated,Substantiated,Physical Abuse +BC132064,38E157,NF,1/3/2013,"RP2 and RP3 were temporary staff providing care to RV. RV became combative as RP2 was changing RV's incontinence product. RP2 called RP3 to help ""hold"" RV's hands and finish RV's care. RV's care plan called for ""not forcing care for RV"", but other interventions were not listed. Both RP2 and RP3 deny observing injury to RV's hands. W4 entered RV's room later on and found bruising to the top of RV's hand and a skin tear. Evidence is not conclusive how or when RV sustained the injury, as RV is known to flail his/her arms, etc. The injury may have occurred after RP2 and RP3 provided care. RV's care plan was amended to out line RV's fragile skin and 6 steps to prevent skin damage. RV was not allowed choice in his/her care; RP2 and RP3 should have stopped providing care. An Oregon Administrative Rule violation occurred.",2,0,Not Substantiated,Substantiated, +OR0000805200,38E157,NF,1/22/2013,"Resident 1 a long term resident with COPD and anxiety experienced continuous difficulty breathing and worsening throughout the day shift on 1/16/2013 without prompt notification to the physician. The resident repeatedly requested his/her inhale, but Staff 4(RP2) failed to address or communicate with the resident's physician regarding the resident's complaints. Staff 5 and 9 continued to tell Staff 4 of the resident's difficulty breathing and requests for help. Staff 4 reported the resident complained he/she could not breath, but the resident did not seem to be in distress and the resident calmed down; opposite recall from the resident, Staff 5 and Staff 9. Staff 8 reported coming on duty at 2:45 P.M. assessed the resident, stated the resident ""looked terrible"", the oxygen level was 79%, physician was notified and the resident was sent to the ER. Staff 8 reported the resident did not receive any oxygen due to the oxygen canister lid not being properly fastened. Staff 4's failure to properly assess; and provide intervention for Resident 1's changing condition and discomfort constitutes neglect of care and abuse. Relevant portions of the survey are attached. A federal civil penalty was imposed. An Oregon Administrative Rule violation occurred.",3,1500,Substantiated,Substantiated,Neglect +OR0000805201,38E157,NF,1/22/2013,"Resident 1 a long term resident with COPD and anxiety experienced continuous difficulty breathing and worsening throughout the day shift on 1/16/2013 without notification to the physician until swing shift staff came on duty. The resident repeatedly requested his/her inhaler and Staff 4(RP2) failed to address or communicate with the resident's physician resident's complaints. Staff 5 and 9 continued telling Staff 4 of the resident's difficulty breathing and requests for help. Staff 4 reported the resident complained he/she could not breath, but the resident did not seem to be in distress and the resident calmed down; opposite recall from the resident , Staff 5 and Staff 9. The resident reported Staff 4 would not listen, finally received the inhaler without relief and Staff 4 told him/her that he/she was ""faking"" it. Additionally Staff 4 failed to give medication as signed for to Resident 1, as well as, residents 2, 3, and 4. Staff 8 also reported the resident did not receive any oxygen due to the oxygen canister lid not being properly fastened. Staff 4's failure to properly assess; and provide intervention for Resident 1's changing condition and discomfort constitutes neglect of care and abuse. Relevant portions of the survey are attached. A federal civil penalty was imposed. An Oregon Administrative Rule violation occurred.",3,0,Substantiated,Substantiated,Neglect +OR0000805202,38E157,NF,1/22/2013,"Resident 1 a long term resident with COPD and anxiety experienced continuous difficulty breathing and worsening throughout the day shift on 1/16/2013 without notification to the physician until swing shift staff came on duty. The resident repeatedly requested his/her inhaler and Staff 4(RP2) failed to address or communicate with the resident's physician resident's complaints . Staff 5 and 9 continued telling Staff 4 of the resident's difficulty breathing and requests for help. Staff 4 reported the resident complained he/she could not breath, but the resident did not seem to be in distress and the resident calmed down; opposite as recalled by the resident , Staff5 and 9. The resident reported Staff 4 would not listen, finally received the inhaler without relief and that Staff 4 told him/her that he/she was ""faking"" it. Additionally Staff 4 told other staff while in the common areas near the resident's room, that the resident was ""faking and not sick"". Staff 4's failure to properly assess and provide intervention for Resident 1's changing condition, increased breathing difficulty/ discomfort, as well as telling the resident he/she is faking/ not sick constitutes neglect of care, significant loss of dignity and constitutes abuse. Relevant portions of the survey are attached. An Oregon Administrative Rule violation occurred.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +CO13109,38E157,NF,6/14/2013,continued medication errors,2,700,Not Substantiated,Substantiated, +BC134010,38E157,NF,8/4/2013,"RV reported RP2 placed RV's brief below RV's nose a number of times, but there were no witnesses. RP2 denied such events. The evidence fails to support or deny such an event. W2 and W3 failed to immediately report the allegation which placed RV at risk. Staff were provided re-education on mandatory reporting. An Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC146367,38E157,NF,3/12/2014,"RP2 refused to assist RV to the bedside commode, told RV ""you are not doing this to me like yesterday' berating RV and used foul language toward RV per W4 and 5. W5 reported RP2 said he/she hated RV in front of RV. RP2 admitted to the investigator saying "" I just put you on the commode, I am not going to put you on the commode again."" W3 (licensed staff) reported prior allegations of RP2 ""belittling"" and making a ""obscene gesture."" W3 reported RP2 had received counseling for his/her tone of voice. The facility knowledge of prior RP2 behavior failed to ensure RV received care of choice; and failed to ensure RV was not exposed to potential and actual verbal/emotional abuse. RP2's actions and verbiage constitutes verbal and emotional abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Verbal/Mental abuse +OR0000880100,38E157,NF,2/26/2014,Resident 1 was admitted January 2014 with diagnoses including Alzheimer's with behavioral disturbances. Resident care plan dated 1/24/2014 identified behaviors and included interventions of a least restrictive nature. On 2/23/2014 at 11:10 P.M. staff found the resident on the floor. The resident refused to get back in bed. Staff provided a blanket and resident care while the resident was on the floor. Staff failed to follow the resident care plan and try other approaches. Portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +BC150034,38E157,NF,1/17/2015,"RV reported waiting three hours to be changed on 1/17/2015, was left in bed ""all day"", no one answered the call light and RP2 came in once saying ""later"". RP3 reported turning off RV's call light and forgetting to turn it back on. RP3 stated asking RP2 to change RV at 9:30 A.M. and again at 11:00 A.M. RP3 reported walking RP2 to RV's room and watching RP2 change RV at about 1:30 P.M. after W4 stated RV had not been changed. RP2 stated not changing RV as RP2 ""could not find other C.N.A. W3 and RP3 deny RP2 asked for any assistance to change RV. Evidence is not conclusive who exactly closed RV's door, but RP2 should have provided care at RP3's direction at 9:30 and 11:00 A.M. While a call light will show at the nurse's station if disconnected, staff are unable to identify which call light is showing. RP2 neglected RV's care resulting in RV's incontinence and or sitting in soiled clothing. A reasonable person would be uncomfortable and embarrassed. RV was also at risk for skin issues. The facility failed to ensure timely care for RV. RP2 and the facility failure to provide prompt/adequate care constitutes abuse. Oregon Administrative Rule violations occurred.",3,250,Substantiated,Substantiated,Neglect +BC150707,38E157,NF,3/19/2015,"RV has a history of fabrication and is care planned for two staff to assist RV. RV denied being harmed by anyone, ""has sex only with cute people"" and had oral sex with RP2. Witnesses report RV gave multiple accounts of his/her actions with RP2. Multiple witness interview found not all staff were reading and or following RV's care plan. RP2 knew RV was a two person assist, but failed to always follow RV's care plan. RP2 failed to document all of RV's behavior, but reported telling the charge nurse. RP2 reported knowing and maintaining boundaries with RV. The facility provided further staff training to follow resident cs. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BC164512,38E157,NF,2/1/2016,RP2 gave RV1 medication that should have been given to RV2. RP2 initialed RV2's medication sheet although RP2 was unable to get RV2 to take the medication. RV1 did complain of not feeling well that evening. RV1's medical provider was notified of the error after RP2's shift ended. RV2's physician was notified that RV2 did not receive medication Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +CO16129,38E157,NF,3/14/2016,"The facility failed to ensure each resident received necessary care and services. Facility Staff 2, Staff 12 and Staff 11 failed to promptly and or adequately assess, monitor, document and inform the physician of Resident 21's changing condition between 3/ 7/ 2016 early A.M. and early A.M. 3/9/2016. Staff failed to monitor Resident 21's CBGs as they were discontinued in error at time of the discontinued Insulin orders. Resident 21 was admitted to the hospital on 3/19/2016 in critical condition with hyperglycemia. Staff and facility failure is identified in the 2567 dated 3/14/2016 attached survey pages; F Tag 309. Further resident review found Resident 14 was at risk for harm when staff provided the resident with continuous oxygen, but physician orders called for PRN use. Review for Resident 13 noted resident assessment of 8/10/2015 identified pressure ulcer risk. The facility procedure indicated staff (usually CNAs) would promptly report skin issues to licensed staff who would assess, report to the resident's physician and initiate treatment. Staff 5 and Staff 7 had not reported Resident 13_x001A_s noted skin changes on 3/9 or 3/10/16. Staff 2 denied receiving reported skin changes on 3/9/2016 at 1:32 P.M. W1 and agency nurse denied knowing of the skin issue on 3/10/2016. While some type of treatment was initiated, there was no physician order or documentation of the resident's skin issues; last note in resident's clinical record was 12/27/2015. + + + +The facility failed to maintain acceptable parameters of nutritional status for Resident 1 and Resident 21. Resident 21 was admitted 12/ 2015 with multiple diagnoses including failure to thrive. Resident 21 lost a significant amount of weight between 1/4/2016 and 2/11/2016; going from 120 pounds to 105 pounds without adequate monitoring, meal replacements being offered and dietician assessment being included in the resident's care plan. In all the resident lost 24 pounds since admission on12/15/2015 as acknowledged by Staff 1. Further resident review found Resident 1 gained 14.6 pounds in one month without the physician being notified or stopping resident's 60 m 2 cal as RD recommended. Multiple staff including administrative staff report knowledge of erroneous weights for residents. The facility failures resulting in resident harm and or potential for harm constitute neglect and abuse. Oregon Administrative Rule violations occurred.",3,3000,Substantiated,Substantiated,Neglect +OR0000809800,38E173,NF,2/3/2013,Multiple staff failed to ensure Resident 23 was placed back in bed according to his/her care plan. Staff observed and repositioned the resident when observing the resident slumping in the wheel chair. Staff assumed other staff were assisting the resident and the resident fell from the wheel chair sustaining injury. A federal civil penalty was recommended. An Oregon Administrative Rule violation occurred.,3,1500,Substantiated,Substantiated,Neglect +BC134192,38E173,NF,8/19/2013,"RP2's comment was reported as witness believed RV heard RP2. RP2 did not deny the comment, but believed RV was asleep and id not hear the comment made to a co-worker. RV was unable to give relevant information. Evidence is inconclusive whether or not RV actually heard the comment. The facility administration ordered RP2 to take classes on cognitive impaired individuals and abuse; placed RP2 on probation and RP2 is to received licensed supervision during probation. The facility confirmed RP2 completed the mandatory training. RP2 reported learning from the training. A Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000843100,38E173,NF,8/6/2013,"Resident 1 was admitted 2005 with multiple diagnoses. Staff 10 reported to Staff 4 on 8/3/2013 resident complaint of arm pain. During the evening shift of 8/3/2013 resident refused to get out of bed which staff 11 reported to Staff 6. Staff 4 and 6 reported the resident either denied pain and or responded ""perhaps"" when asked about pain. Staff 6 denied recalling any resident complaint of pain at shift change and checked the resident during the evening shift when the resident complaint of pain was reported. At the time of the survey there was no documentation in the clinical record of the resident's reports of pain during the day or evening shift of 8/3/2013. The facility failed to adequately assess the resident's complaints of pain resulting in the resident's fracture not being assessed or treated in a timely manner and resident not receiving timely pain management. The facility failure constitutes abuse. Relevant portions of the survey are attached. Oregon Administrative Rule violations occurred.",3,1500,Substantiated,Substantiated,Neglect +BC116851,38E174,NF,4/22/2011,,2,0,Not Substantiated,Substantiated, +OR0000700000,38E174,NF,7/18/2011,Resident #1 was assessed as a fall risk and identified interventions were care planned; including a directive not to leave Resident #1 unattended in a wheelchair. On 7/14/2011 Resident #1 was alone in a dayroom and fell out a wheelchair onto the floor with no injury noted. The facility failed to provide adequate care and services regarding Resident #1's 7/14/2011 fall.,2,0,Not Substantiated,Substantiated, +OR0000697100,38E174,NF,6/30/2011,Evidence and interviews indicated facility failure to ensure care plan interventions were implemented to prevent Resident #1's 6/24/2011 fall with injuries. Relevant portions of the survey report are attached.,2,300,Substantiated,Substantiated,Neglect +OR0000732200,38E174,NF,12/5/2011,Evidence and interviews indicated the facility failed to provide the necessary care and services to prevent a physical altercation involving Resident #1 and Resident#2 resulting in both residents sustaining injuries and Resident #2's subsequent death. Relevant portions of the complaint report investigation are attached; federal penalty recommended.,4,4000,Substantiated,Substantiated,Neglect +OR0000732300,38E174,NF,12/5/2011,Evidence and interviews indicated facility failure to provide care and services on 12/1/2011 to prevent a resident-to-resident altercation between Resident #1 and Resident #3 resulting in Resident #1 sustaining injury requiring hospital treatment. Relevant portions of the complaint report are attached; federal penalty recommended.,3,1500,Substantiated,Substantiated,Neglect +OR0000745700,38E174,NF,2/17/2012,Evidence and interviews indicated facility failure to ensure RP2 (CNA) referred to as W1 (CNA) in the complaint report investigation and facility staff provided Resident #3 adequate transfer assistance on 02/09/2012. Resident #3 sustained a fall and complained of left knee pain and tenderness. Relevant portions of the complaint report investigation are attached.,2,250,Substantiated,Substantiated,Neglect +BC121499,38E174,NF,10/30/2012,Evidence and interviews indicated facility failed to assure Resident #1's safety resulting in Resident #1's elopement from the facility.,3,250,Not Substantiated,Substantiated, +OR0000841000,38E174,NF,7/23/2013,"Evidence and interviews indicated facility failure to provide adequate supervision and update care plan interventions related to Resident #1's elopement from the facility. Resident #1 sustained a fall and a dislocated shoulder during an elopement, this failure is considered neglect of care and constitutes abuse. Federal penalty recommended, relevant portions of the complaint report investigation are attached.",3,,Substantiated,Substantiated,Neglect +BC153155,38E174,NF,8/18/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from the alleged theft of $1,400 sometime during December 2014. The initial alleged theft of December 2014 was reported to Adult Protective Services on or about 10/13/2015. Facility staff have keys to resident locking drawers and resident keys are not unique to individual locking drawers. Resident #1 indicated RP2 (facility staff) might have taken her/his money, however RP2 was unavailable to interview. The facility failure to protect Resident #1 from financial exploitation resulting in Resident #1 sustaining a loss of money is a violation of resident rights, considered financial exploitation, and constitutes abuse.",3,,Substantiated,Substantiated,Financial abuse +OR0000701900,38E188,NF,7/25/2011,"resident 1 was admitted August 2008 with diagnoses including cognitive impairment. Resident 1's 5/18/11 assessment identified memory problems and severely impacted cognitive skills. The 5/18/11 assessment noted total dependency for toileting, was not steady and able to stabilize self with staff assistance. The care plan of 7/3/11 provided varied intervention for fall risk including ""staff"" not to leave resident unattended on the toilet. On 7/22/11 Staff 4 reported leaving Resident 1 alone for approximately ""one minute"" to retrieve supplies and found Resident 1 on the floor. Staff 4 did not expect Resident 1 to move that quickly. Staff 2 determined Resident crawled off the toilet and then fell from a kneeling position. Resident 1's injury was minor and there was no evidence of ""pain."" Relevant portions of the survey are attached. A directed in-service was proposed.",2,0,Not Substantiated,Substantiated, +OR0000712500,38E188,NF,8/30/2011,"While Staff 3 failed to initiate a neuro check sheet, Staff 3 did complete neuro checks at least once. Staff 3 reported telling Staff 4 that Resident 1 fell, but failed to tell Staff 4 that Resident 1 struck his/her head. No staff had notified the physician that Resident 1 had fallen by the evidence presented. Staff did place Resident 1 on alert and did monitor vital signs. Resident 1 was at risk for harm.",2,0,Not Substantiated,Substantiated, +OR0000752201,38E188,NF,3/27/2012,"Based on observation, interview and record review it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was free from significant medication errors. As a result, Resident 1 became unresponsive and required hospitalization. Between 1/8/2012 and 3/22/2012 RP2 (Staff 7) made multiple preventable medication errors. The errors placed Resident 2, Resident 3 and Resident 4 at risk for harm. RP2 received counseling, but continued to make medication errors. On 3/22/2012 RP2 gave Resident 1 his/her roommates medication, failed to promptly report the error to a licensed nurse and gave Resident 1 his/her scheduled medication without direction from a licensed nurse or physician to determine safety in giving Resident 1_x001A_s medication in addition to having given the roommate_x001A_s medication. Additionally, RP2 falsely documented spilling and wasting the roommate_x001A_s medication. Resident 1 ended up in the hospital ultimately due to medication error. RP2_x001A_s behavior and actions resulted in resident harm and constitutes abuse.",3,1500,Substantiated,Substantiated,Neglect +BC146772A,38E188,NF,4/12/2014,"RV1's MAR indicated Tylenol #3 prescription ended 4/11/2014, but in fact it was to end 4/12/2014. RV's physician appointment of 4/11/2014 was rescheduled to 4/18/2014 and staff sent a request to renew the Tylenol #3 prescription on 4/11/2014, but failed to contact the physician promptly when there was no reply to the request on either 4/11 or 4/12/2014. RV did not receive the Tylenol #3 on 4/12/2014 and sustained pain on at least two occasions per W4. The facility failure resulted in minor with potential for moderate harm which constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +OR0000856800,38E195,NF,10/7/2013,Resident 1 was admitted 6/2013 with multiple diagnoses and a temporary care plan identified need for mobility and transfer assistance. Resident sustained various falls without a thorough facility investigation and adequate care plan interventions adopted. On 9/2/2013 resident sustained an witnessed fall and a fractured hip. Relevant survey pages are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +OR0000856804,38E195,NF,10/7/2013,Resident 1 was admitted 6/20013 with multiple diagnoses. The resident was independent with eating and weighed 279 pounds. The resident sustained notable weight loss without adequate assessment and care plan interventions. Relevant portions of the survey are attached. A federal civil penalty was proposed. Oregon Administrative Rule violations occurred.,3,,Substantiated,Substantiated,Neglect +OR0000922200,38E195,NF,9/18/2014,"Resident 2 was admitted 2013 with multiple diagnoses including behaviors, blindness, etc. as detailed in the attached survey report. The facility failed to implement policy and procedures regarding investigation and reporting reports of abuse. Staff 13 and 17 reported Staff 22 telling the resident staff would break resident's call light. Staff found the call light tucked behind resident's mattress; out of reach. Evidence is not conclusive who stuck the light behind the mattress. The complaint went to corporate office, but was not reported to APS leaving the resident at risk for harm. During the investigation it was found Staff 22 worked as a C.N.A. with an expired certification. Relevant portions of the survey are attached. An enforcement was proposed. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +OR0000922201,38E195,NF,9/18/2014,"Resident 2 was admitted 2013 with multiple diagnoses including behaviors, blindness and many other diagnoses as described in the attached report. Based on observation, record review and witness interview, it was determined the facility failed to incorporate mental health recommendations as part of resident's behavioral care plan. Staff were not well informed of the resident's care plan, the facility failed to document incidents of behavior with interventions and follow care plan interventions. Resident behaviors escalated and the resident was sent to the hospital without family notification relevant portions of the survey are attached. Enforcement action was proposed. Oregon Administrative Rules were violated.",2,,Not Substantiated,Substantiated, +OR0000922202,38E195,NF,9/18/2014,"Based on observation, interview and record review it was determined the facility failed to honor a resident's right to return after hospitalization. Resident was sent to the hospital on 9/12 and 13/2014 without contacting the family to provide care plan intervention. The facility would not initially allow the resident to return. Relevant portions of the survey are attached. Enforcement action was recommended. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OT151236,38E195,NF,4/9/2015,"RV became upset in believing RV had no choice to speak regarding a smoking policy. RV and RP2 often took smoke breaks together during which time RP2 brought up a ""new smoking policy"" and how that policy would not effect RP2, but would effect RV and other residents. RP2's statements created the perception that RV would be deprived of tobacco if RV went to the hospital or extended care and returned to the facility. During an employee orientation there was mention of a distant and only a ""thought"" that the facility would become nonsmoking, but RP2 had not verified the information before speaking which caused distress to RV. The facility failed to ensure all employees were in serviced regarding policy/procedure and what should not have been mentioned in the facility curriculum. The facility failure resulted in RV's distress, fear, wanting to change to DNR and not wanting to live. This facility failure constitutes neglect and abuse. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Neglect +BC150594,38E196,NF,3/14/2015,"Evidence and interviews indicated facility failure to follow Resident #1's care plan related to an incident on 3/14/2015 where Resident #1 was left sitting in her/his wheelchair next to Resident #2. Witness #7 (staff) said she/he observed Resident #1 fondling Resident #2 in the ""crotch area."" Resident #1's 3/14/2015 care plan was updated to indicate Resident #1 should not be placed where her/his arms could reach other residents. On 3/16/2015, Resident #1 was seated in her/his wheelchair in the dining room next to an opposite gendered resident at dinnertime.",2,,Not Substantiated,Substantiated, +BC164925,38E196,NF,3/9/2016,"Evidence and interviews indicated facility failed to assure Resident #1, Resident #2, and Resident #3's individual rights' to be treated in a considerate, respectful manner when receiving care and services from RP2 (CNA) during March 2016. The facilities internal investigation regarding RP2's care services when assisting Resident #1, Resident #2, and Resident #3 concluded RP2's services were not considered abusive however were inappropriate.",2,,Not Substantiated,Substantiated, +OR0000831200,38L400,NF,5/21/2013,"Record review by the investigator revealed staff late entries and summary of some resident concerns, but no on going documentation related to medication concerns. There was incomplete and inaccurate documentation to Celexa administration. Staff failed to provide followup to physician orders and Gero-pyschological consult. The resident was placed at risk for ineffective treatment of depression. Relevant pages of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +OR0000831202,38L400,NF,5/21/2013,"Resident 1 was admitted 5/10/2013 with diagnoses including dysthymic disorder. The physician orders included specific medication and dosage orders for Celexa. On 5/13/2013 the dosage order was decreased, but the resident did not receive Celexa in any dosage between 5/10/2013 and 5/23/2013. Staff failed to inform the resident of risk and benefits of refusing medication. Staff failed to inform the resident's physician and the Gero-pyschological consultant of the resident's refusal of medication. The resident exhibited anxiety and sadness which may have been related to his/her refusal of the Celexa. The resident was at risk for side effects and harm when refusing medication; and staff's failure to promptly notify the physician of resident's refusal of medication. Relevant pages of the survey are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +OR0000835300,38L400,NF,6/13/2013,Resident 1 was admitted 4/18/2013 with multiple diagnoses including a hip fracture. Resident 1 complained of long call light response times. Review of the computerized response times revealed nine times exceeding fifteen minutes. The resident reported not drinking fluids due to call light concerns. The resident was to drink a liter of fluids per day per physician orders. Staff failed to adequately monitor the resident fluid intake. Relevant portions of the survey are attached. Enforcement action was taken. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000835301,38L400,NF,6/13/2013,The resident reported not drinking fluids due to call light concerns. The resident was to drink a liter of fluids per day per physician orders. Staff failed to adequately monitor the resident fluid intake. Relevant portions of the survey are attached. Enforcement action was taken. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000852900,38L400,NF,9/13/2013,"Resident 1 was admitted June 2013 with diagnoses including a stroke with right hemiparesis. Resident care plan identified fall with with interventions being care planned. Staff 10 left resident alone on the toilet reportedly telling Staff 9 to check on the resident. Neither staff were in the resident's room during the conversation. Staff 10 ""assumed"" Staff 9 knew what care to provide; Staff 9 denied caring for the resident before and reported Staff 10 did not tell Staff 9 the resident required supervision in the bathroom. Miscommunication between staff resulted in the resident falling and sustaining minimal injury. Enforcement action was recommended an Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BC135118,38L400,NF,7/31/2013,"RV reported withdrawing $100.00, clipping the money with RV's credit card and placing the money/card in RV's purse. RV kept his/her purse on the bedside table. Witnesses reported encouraging resident not to keep valuables in their rooms. Evidence was insufficient to note whether or not RV had access to a lockable area in his/her room and whether or not RV wished to use a lockable area. W1 reported the ""stolen'"" credit card/money was reported 7/15/13. RV thought he/she had misplaced the money when looking for cash/credit card on 7/10/2013, but realized later the card had been stolen when the credit company reported attempts to use the card in a number of places. W5 reported no chronic problem with theft at the facility. While all staff interviewed denied knowledge of the missing money/credit card it is more likely than not the theft was completed by staff. The facility failed to ensure a safe environment resulting in theft of RV's money and credit card which constitutes abuse. The facility reimbursed RV's money and RV's credit card account was closed. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +MM147188,38L501,NF,5/20/2014,"RV requested pain medication after receiving Norco pain medication at 2:21P.M. on 5/20/2014, but did not receive narcotic medication as ordered until 5/22/2014 at 10:08 P.M. RV received Tylenol with little effect. Staff had requested a new prescription from RV's physician on 5/16/2014 and called the physician on 5/20/2014 when the physician failed to send a new prescription. Staff failed to inform RV and or RV's family the Norco prescription was not available. Staff failed to obtain other pain medication for RV equivalent to the narcotic medication RV had been regularly receiving. W3 reported RV had pain so bad RV could not move. The facility failed to have an adequate medication system to ensure RV and potentially all other residents re-order medication was tracked; the medication obtained timely; and RV and/or other residents received the pain medication as physician ordered. RV sustained continued pain and discomfort without timely or adequate intervention. The facility failure constitutes neglect and abuse. Oregon Administrative Rule violations occurred.",3,400,Substantiated,Substantiated,Neglect +MM151157,38L501,NF,4/1/2015,"From 4/1/2015 to 4/5/2015 RP2 took approximately 32 Oxycodone pills from RV1, RV2, RV3 and RV4 for RP2's personal use. Through the facility's process for counting narcotics and astute staff noting medication irregularities regarding RV's medication the medication discrepancies were quickly recognized. The facility notified the agency who sent RP2, notified OSBN and notified LEA in a timely manner. Additionally it was found that at the time RP2 was working for the facility RP2 did not possess a valid nursing license. Both the agency and the facility believed RP2 was a licensed LPN in good standing. The agency hired RP2 in September 2014 and RP2's license was unencumbered. RP2 voluntarily surrendered his/her license in November 2014, but failed to tell the agency at the time and failed to tell the facility he/she was not licensed when coming to work at the facility. RP2's theft of resident medication for his/her personal use constitutes abuse. Oregon Administrative Rule violations occurred.",3,,Not Substantiated,Substantiated,Financial abuse +AL152250,38L503,NF,7/9/2015,The facility suspected diversion of RV's narcotic medication by RP2. Record review noted RP2 gave narcotics to RV at night when other staff did not. RP2 tested positive for the narcotic in question. RP2 refused to talk with police. RV was unable to give relevant information. The facility system was not adequate for tracking RV's narcotics. Evidence was insufficient to identify what happened to RV's medication. Oregon Administrative Rule violations occurred.,2,,Inconclusive,Substantiated, +MV164314,38L503,NF,12/25/2015,"The complainant reported $137.00 went missing from RV's wallet on 12/25/2015 and $100.00 was also taken in November. Various dates, times and the amount of monies are given by W1 and RV. W2, 3,4,5,6, and 7 report ""hearing"" about missing money. Witnesses continue to talk to RV regarding locking the money in his/her lock box, using the PIF account or using the facility safe. Police were contacted per report #16-441 dated 1/12/2016. RV received reimbursement. Evidence is inconclusive as to who may have taken RV's money. An Oregon Administrative Rule violation occurred.",2,,Inconclusive,Substantiated, +AL164444,38L503,NF,1/26/2016,"The facility failed to ensure RV's O@ concentrator humidifier was filled with water. RV reported staff assisted RV right away and this was the first time this has occurred. After staff assisted RV, RV's breathing did improve. RV was at risk for harm due to delayed use of the O2 concentrator. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +AL152004,38L503,NF,6/19/2015,"The complainant 1 reported the POA RV1 lost $200.00 from RV's locked drawer. Complainant 1 reported RV1 refused to put the $200.00 in the client savings account. Witnesses, Complainant 1 and documentation indicate RV loses things frequently, RV1 keeps the key to the locking drawer lying around or in the drawer. Staff failed to adequately care plan RV1's behavior regarding losing items and or keeping the key in the drawer. Staff searched for the money, notified law enforcement and SPD regarding the missing money. The money was replaced. Oregon Administrative Rule violation occurred.",2,,Substantiated,Substantiated,Financial abuse +BH118645,38L544,NF,12/5/2011,RV's medication was kept in an unlocked refrigerator in a locked medication room. Two vials of medication went missing and the facility notified police and PAS. Evidence is inconclusive who took the medication. The facility will reimburse RV for the medication and has placed a lock box for refrigerator narcotics.,2,0,Substantiated,Substantiated,Financial abuse +BH129234,38L544,NF,2/9/2012,"W1 reported a box of patches, which were locked in the medication cart, have gone missing. The patches were no narcotic. Per witness statement staff have no idea what happened to the medication. RV didn't sustain negative effects and the facility replaced the patches. The facility failed to provide a safe medication system resulting in theft (financial abuse) and a violation of Oregon Adminisitrative rule.",2,0,Substantiated,Substantiated,Financial abuse +BH132921,38L544,NF,4/9/2013,"The facility moved RV1 into RV2's room knowing RV1 preferred dim light and the TV off. RV2 and witnesses reported RV1 continued to get into RV2's things and turn RV2's TV off. RV2 had a history of lowered feelings and recent increased frustration. RV2 ran his/her motorized wheel chair into RV1. RV1 did not sustain injury. The facility failed to adequately document, intervene and or care plan RV1 and RV2's behaviors; and or frustration for over a month long period of time. The incident was preventable. An Oregon Administrative Rule violation occurred.",2,200,Not Substantiated,Substantiated, +OR0000882100,38L544,NF,3/11/2014,Resident 1 was admitted 2010 with multiple diagnoses including severe dementia. W1 was listed as POA and health care representative. On 2/23/2014 staff noted resident's left leg to be red and swollen; physician notified. Staff monitored resident's leg as ordered and antibiotics were initiated on 3/4/2014 after a physician examination. Resident was sent to the hospital with diagnosis of cellulitus on 3/8/2014. staff failed to notify W1 regarding the change in resident's leg and the start of antibiotics. Relevant portions of the survey re attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.,2,,Not Substantiated,Substantiated, +OR0000930100,38L544,NF,10/29/2014,"Resident 1 was admitted in 2011 with multiple diagnoses including abnormal gait, dementia and a history of falls. Resident's 10/14/2014 MDS and assessment indicated the resident continued to have falls; some with injury. The resident's care plan identified fall risks with varied interventions in place which included fifteen minute checks between 2 7 3 P.M.; 60 minute checks all other times. The resident was toileted at approximately 1: 30 P.M., but not checked on until 3:30 P.P. The resident was found on the floor at 3:30 P.M. after staff responded to resident's call light. Exactly when the resident fell was not determined. The resident sustained abrasions. It was determined staff failed to follow the resident care plan and check the resident every 15 minutes. Relevant survey pages are attached. Enforcement action was proposed. Oregon Administrative Rule violations occurred.",2,,Not Substantiated,Substantiated, +BH153382A,38L544,NF,6/17/2015,"RV was dropped off at the hospital for a blood transfusion; RV was unaccompanied; RV's condition was compromised, RV was unable to answer questions and was ""unresponsive"". The facility failed to ensure RV's safety. Oregon Administrative Rule violation occurred.",2,,Not Substantiated,Substantiated, +BH151405,38L544,NF,5/8/2015,"RV reported missing $100.00 from a drawer in a desk in RV's room. W1 (facility staff) installed a camera in RV's room with RV's permission, W1 placed two $100.00 bills in the drawer and observed RP2 take the money from the drawer. The facility notified the police, paid RV $100.00 for the original missing money, RP2 was terminated from employment and arrested. RP2 acknowledge receiving APS business card, but failed to respond to request for interview. The investigator observed RP2 had received a hand book regarding theft. Preponderance of evidence supports RV's theft of monies by RP2 and the invasion of RV's personal space resulted in abuse. Oregon Administrative Rules were violated.",3,,Not Substantiated,Substantiated,Financial abuse +BH133479,38L544,NF,6/6/2013,"The facility failed to provide a safe environment for RV1 and RV2. RV2 struck RV1 in the left side of the head. RV1 sat down at the table where RV2 was sitting, RV1 took one of RV2's papers, RV2 struck RV1, RV1 denied discomfort and no injury was noted. RV1 was care planned to not re around RV2, but staff failed to follow the care plan. The incident was foreseeable and preventable. Facility neglect of care constitutes abuse. Oregon Administrative Rule violations occurred.",2,,Substantiated,Substantiated,Neglect +MM120106,38L565,NF,5/17/2012,Evidence and interviews indicated facility failed to ensure adequate care planning for the care and safety of assisting Resident #1 with transfers. Resident #1 sustained bruising as a result of inadequate transfer assistance.,2,0,Substantiated,Substantiated,Neglect +OR00006664,38L756,NF,2/4/2011,"On January 6, 2011 staff #3 assisted Resident #1 in the bathroom; Resident #1 had a gait belt around the waist and used a transfer bar to stand. Resident #1_x001A_s knee gave out and staff #3 assisted Resident #1 to the floor by holding onto the gait belt. January 7, 2011 notes revealed Resident #1 sustained an acute fracture of the left lower leg. Relevant portions of the survey report are attached.",3,500,Substantiated,Substantiated,Neglect +ES116352,38L756,NF,2/10/2011,Resident #1_x001A_s January 2011 care plan had contradictory information about whether or not Resident #1 required one or two-person transfer assistance. On 2/10/2011 RP2 (CNA) was providing Resident #1 with showering assistance. Resident #1 started to sit down in the middle of the shower; RP2 put her/his knee out for Resident #1 to sit on and lowered Resident #1 to the floor. RP2 scratched the top of Resident #1_x001A_s hand and caused a skin tear.,2,0,Substantiated,Substantiated,Neglect +ES135253,38L756,NF,11/25/2013,"Evidence and interviews indicated facility failure to protect Resident #1 from the theft by an unknown person of her/his rings valued at approximately $20,000. Evidence and interviews indicated the facility reimbursed Resident #1's family for the value of the stolen jewelry.",3,,Not Substantiated,Substantiated,Financial abuse +ES151440B,38L756,NF,6/2/2015,"Evidence and interviews indicated facility failure to protect Resident #1 from the theft of her/his earrings in June of 2013. In addition, evidence and interviews indicated facility failure to adequately report the theft of Resident #1's jewelry to law enforcement and the Department. The facility failure to protect Resident #1 from theft resulting in Resident #1 sustaining a loss of her/his jewelry are violations of resident rights, are considered neglect of care, and constitute abuse. + + + +Please note: Other Resident #1 jewelry reported as stolen in this report were not reportedly taken when Resident #1 resided in the nursing facility area of the facility.",2,,Substantiated,Substantiated,Financial abuse +MV129668,500175,AFH,4/1/2012,"On or about April 1, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to administer medication as ordered to Reported Victim (RV). On 3/31/12 RV was admitted to the emergency room and RV missed h/her 8:00pm medication. RV returned to the adult foster home (AFH) on 4/1/12 at 2:45am with no discharge paperwork from the hospital. Reported Perpetrator #3 (RP3) administered RV's 8:00pm medication at 3:00am without orders to do so. RP3 then administered RV's medication at 8:00am as ordered resulting in only 5 hours between medication administration. On 4/1/12 at approximately 12:00pm RV's blood pressure reading was 68/50. Reported Perpetrator #2 (RP2) contacted RV's family and RV was admitted to urgent care where RV's blood pressure reading was 80/40. The licensee failed to administer medication as ordered to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +WB145709,500211,AFH,12/15/2013,"On or about December 18, 2013, it was alleged that Reported Perpetrator (RP) failed to intervene when Reported Victim's (RV) condition changed. RV goes for walks around the neighborhood frequently. RP has instructed caregivers to attempt to re-direct RV if RV wishes to go for a walk. If the caregiver cannot re-direct RV then caregiver is to observe what direction RV is walking and if RV does not return in 15 minutes then caregiver is to contact 911 and/or RP. On 12/14/13 RV was discovered by a neighbor to be wandering and confused. RV was brought back to the adult foster home (AFH) without injury. On 12/15/13 RV was discovered wandering and confused approximately 3/4 of a mile from the AFH. Law enforcement was contacted. RV was brought back to the AFH without injury. On 12/16/13 an employee from Roth's market approached the AFH and stated that RV had appeared lost and confused and was in the market drinking coffee. Law enforcement was contacted and RV was returned to the AFH without injury. Witness #1 (W1), Witness #2 (W2) and Witness #4 (W4) agree that it is unsafe to allow RV to walk alone due to his/her condition. The licensee failed to intervene when RV's condition changed. The failure is a violation of Oregon Administrative Rule.",2,,,, +ES105886B,500452,AFH,12/1/2010,"On or about November 28, 2010 December 11, 2010, Licensee failed to obtain complete physician orders and failed to administer medications to Resident 1 per physician orders. Licensee failed to list all of Resident 1's medications on the medication administration record and failed to have all of Resident 1's medications available in the Adult Foster Home. Licensee failed to conduct a screening and assessment of Resident 1 prior to admitting him/her into Licensee's home.",2,150,,, +CO11049,500452,AFH,3/2/2011,,0,200,,, +MS117876A,500598,AFH,9/1/2011,"On September 1, 2011, it was reported that Resident #1 (RV1) had been yelled at by Reported Perpetrator #2 (RP2). Interviews indicated that RP2 had yelled at RV1 and slammed the kitchen door in RV1's face, which caused RV1 emotional distress. The investigation concluded that the Licensee failed to protect RV1 from harm.",2,0,,,Verbal/Mental abuse +MS117876B,500598,AFH,9/1/2011,"On September 1, 2011, it was alleged that Reported Perpetrator #2 (RP2) had been physically rough with Resident #2 (RV2). Interviews indicated that RP2 had yanked RV2's clothes off and grabbed RV2's arm on one occasion. Licensee failure to protect RV2 from harm was substantiated.",2,0,,, +MS129185B,500598,AFH,2/8/2012,"It was reported that on or about February 8, 2012, Licensee failed to protect Resident #1 from rough treatment. Reported Perpetrator #3 was inexperienced, attempted to change Resident #1's clothes and as a result of resident #1 having fragile skin he/she sustained a skin tear. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of Licensee was substantiated.",2,0,,, +MS133898,500598,AFH,7/24/2013,"Resident #1 was admitted to licensee's adult foster home on July 1, 2013. Resident #1 required full care with all activities of daily living. Licensee acknowledged that Resident #1 did not have any sores or wounds when Resident #1 was admitted to the AFH. On July 18, 2013, facility records indicate that an open sore was identified on Resident #1's tailbone and Resident #1's right buttock was described as very red. Cream was applied without a medical order. On July 19, 2013, the redness on the right buttock had opened. Cream was again applied without a physician's order. On July 20, 2013, staff became aware that Resident #1 had a pressure blister on each heel. During the investigation, Licensee reported that the facility was having some trouble with Resident #1's wounds. The licensee further stated that the caregivers would do Resident #1's wound care and that they did not have orders to provide wound care. Resident #1 was not seen by a medical professional until July 25, 2013. The facility failed to intervene when Resident #1 experienced a change in condition and failed to obtain medical orders prior to providing wound care. These failures are violations of resident rights, are considered neglect and constitute abuse.",2,,,,Neglect +MS134538A,500598,AFH,9/12/2013,"Resident #1's (RV1) care plan indicates that he/she has a history of being combative. Witnesses #3 (W3) and #5 (W5) reported that Reported Perpetrator #2 (RP2) yelled at and hit RV1 with an open hand. When W3 mentioned that hitting residents is against the law, RP2 said it way okay because RV1 was combative. Reported Perpetrator #3 (RP3) reported that RP2 would grab RV1 by the arm and shove RV1 into RV1's room. + + + +W3 also mentioned during his/her interview that RP2 advised him/her that Resident #2 (RV2) should always be wheeled backward. RP2 said this as he/she was wheeling RV2 forward. RV2's foot was run over by the wheeled assistive device. RV2 and W3 immediately checked RV2's foot and discovered it was discolored. + + + +Witness #4 (W4) and RP1 and RP2 all indicated that RP3 was rough with residents. RP1 stated in his/her interview that RP3 had been previously warned about treating residents roughly but was not fired. + + + +W5 stated that RV4 was ""manhandled"" and R4 was observed to have skin discoloration of unknown origin. + + + +No incidents were documented by the facility. RP1 failed to report abuse or suspected abuse to the department. Licensee's failure to act upon reported abuse of residents is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +MS134538B,500598,AFH,9/12/2013,"Witness #3 (W3) reported that the facility purees food for all residents, even for those not on special diets. None of the residents have physician's orders for pureed food. Resident #1 (RV1) is the only resident with capacity to report displeasure. Witness #5 (W5) stated that caregivers blend everyone's food because it is faster and convenient for the staff. Reported Perpetrator #2 (RP2) stated that he/she did not know doctor's orders were needed for residents to be given pureed food. Licensee failed to ensure that residents' preferences for meal choices were considered. Licensee's failure is a violation of Oregon Administrative Rule.",2,,,, +AL153469A,500864,AFH,9/22/2015,"It was reported that on or about September 22, 2015, Licensee failed to protect Resident #1 from wrongful use of physical restraint. On September 15, 2015, Licensee physically held Resident #1 down on the floor until emergency responders arrived. Licensee's use of physical force to hold Resident #1 down on the floor is a violation of AFH OARs. Wrongdoing on the part of the Licensee is substantiated.",2,,,, +AL153469B,500864,AFH,9/22/2015,"It was reported that on or about September 22, 2015, Licensee failed to protect Resident #1 from physical injury. On September 22, 2015, Licensee and Witness #2 (W2) had an interaction with Resident #1 and Resident #1's behavior escalated. Resident #1 stood up out of his/her wheelchair and made physical contact with Licensee and fell to the floor. Licensee then held Resident #1 on the floor using her hands and pressing down on Resident #1's shoulders. Resident #1 sustained scratches and bruising as a result of Licensee physically restraining Resident #1. Licensee's failure is a violation of AFH OARs, and is considered physical abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Physical Abuse +CO14024,501086,AFH,10/24/2013,,3,250,,, +CO14025,501086,AFH,10/24/2013,Advisory letter issued for repeat history of failing to ensure all caregivers completed the preparatory workbook and orientation.,2,,,, +CO14079,501086,AFH,4/7/2014,Request for conditions: ROA plus barring each of licensee's daughters for both homes. Not issued. CP instead for repetitive RM/not living in home issues.,2,,,, +MS150309B,501086,AFH,2/4/2015,"On or about 2/19/15, APS received a complaint that facility caregivers were inappropriate toward RV, both verbally and in written documentation. During the course of the investigation, APS determined that RP2 was verbally harsh toward RV and spoke to facility visitors about RV in a denigrating fashion. APS also determined that facility written documents were written in a denigrating manner toward RV. The facility's failure to treat RV as an adult with respect and dignity is a violation of Resident Rights and is a violation of Oregon Administrative Rule.",2,,,, +ES117547,501126,AFH,7/22/2011,"Reported Victim #1 (RV1) developed an infection below the right knee. RV1 was transported to RV1_x001A_s physician by a family member on July 15, 2011. RV1 was prescribed an oral antibiotic for the infection. On July 22, 2011, RV1_x001A_s infection had advanced and RV1 was hospitalized and was placed on IV antibiotics for four days. RV1_x001A_s condition was not properly monitored or cared for which resulted in a decline of RV1_x001A_s infection. The facility failed to adequately assess and intervene for RV1_x001A_s condition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +ES117595,501126,AFH,7/28/2011,"On or about July 29, 2011, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), and Reported Victim #5 (RV5). It was determined that RP used threats, intimidation, and insults toward RV's. RP failed to protect RV's from mental or emotional abuse.",2,0,,, +AL118386,501160,AFH,10/13/2011,"On October 23, 2011, Resident #1 (RV) reported that he/she was experiencing right leg pain. Reported Perpetrator #2 (RP2) placed a heating pad on RV's right leg and left RV alone. RV has a condition that affects sensation and limits his/her ability to accurately perceive and report types of pain. As a result, RV developed a blister on his/her thigh during use of the heating pad. The facility failed to monitor RV while the heating pad was being used. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",3,0,Not Substantiated,Substantiated,Neglect +CO14087,501160,AFH,4/7/2014,3 mandatory smoke alarm issues and 2 unqual cg events,3,1250,,, +KF103814,501350,AFH,3/21/2010,"On or about March 21, 2011, it was reported that the Licensee failed to provide a safe environment for Resident #1 (RV1). RV1 had 13 documented falls between October 3, 2009 and March 21, 2010 as a result of self transfering. Licensee failed to provide adequate staffing to meet RV1's care needs. Facility staff had to contact 911 on 6 separate occasions to assist in getting RV1 off the floor after falling. RV1 sustained minor injuries as a result of at least 4 of the falls. Wrongdoing on the part of the Licensee was substantiated.",2,200,,, +KF104166,501350,AFH,4/30/2010,"On or about April 30, 2010, it was reported that the Licensee failed to protect Resident's (RV's) from involuntary seclusion. RV's go to there bedroom after dinner and are not allowed out of there rooms after about 8:30 PM. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Involuntary Seclusion +CO15118,501532,AFH,6/19/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +CO15124,501532,AFH,6/22/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +CO12119,501591,AFH,10/2/2012,"Resident Manager's criminal record check had expired April 11, 2012. MARs indicated DM had worked multiple days in September 2012.",3,200,,, +KF148186,501591,AFH,8/1/2014,"On or about 8/19/14, Adult Protective Services received an allegation that RP failed to provide appropriate service. During the course of the investigation, APS substantiated the following: RV had lived in RP's adult foster home before transferring to W1's home on 8/1/14. While at RP's, the RV needed assistance with cleansing after elimination and keeping skin areas treated. RP and W3 stated that RV did not have any wounds prior to leaving the facility, however W2 and W4 observed RV's wounds while RV still lived at RP's adult foster home. W2 and W4 observed that RV's wounds were treated with an unknown brand of cream and powder. RV moved into W1's home and RV complained about genital area hurting. W1 discovered an open wound on RV's coccyx and genital area. W1 could not treat RV's wounds until a physician assessed RV. W1 contacted RV's spouse who determined RV could wait for treatment until regularly scheduled appointment on 8/12/14. RV was sent to the emergency room on 8/9/14 with a 5cm area of redness and 1 cm of broken skin. RV passed away on 8/10/14 due to decline in physical condition unrelated to wounds. RP's failure to provide appropriate servicesis a violation of resident rights, constitutes neglect, and is considered abuse.",3,,,,Neglect +CO12025,501639,AFH,2/15/2012,"On February 15, 2012, the licensor conducted a renewal visit at the licensee_x001A_s Adult Foster Home (AFH). During the visit the licensor found that the AFH common room and hallway did not have the required smoke alarms installed. The licensee failed to provide a safe environment. The licensee_x001A_s failures are a violation of Oregon Administrative Rules.",3,250,,, +CO11009,501760,AFH,12/14/2010,,2,250,,, +MM118711,501760,AFH,11/21/2011,"On or about November 21, 2011, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from financial exploitation. It was determined that RP conveyed threats toward RV to wrongfully take money from RV. As a result RV felt intimidated and pressured. The licensee failed to protect RV from financial exploitation resulting in RV's loss of funds. The failure is a violation of resident rights and constitute abuse.",2,0,,,Financial abuse +GP134333C,501830,AFH,9/6/2013,"On or about September 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from involuntary seclusion. RV grinds his/her teeth due to medications. On multiple occasions RV was taken outside on the porch in a wheelchair. On at least one occasion Witness #2 (W2) observed RV on the porch in the wheelchair with a gait belt wrapped around RV and the wheelchair. Reported Perpetrator #3 (RP3) acknowledged putting RV on the porch and wrapping a gait belt around RV and securing the ends of the gait belt to the wheelchair. The licensee failed to protect RV from involuntary seclusion. The failure is a violation of resident rights, is considered involuntary seclusion and constitutes abuse.",2,,,,Restraints +GP134333A,501830,AFH,9/6/2013,"On or about September 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV's medication cause RV to grind his/her teeth. Reported Perpetrator #2 (RP2) instructed Witness #2 (W2) and Witness #5 (W5) to put RV on the porch if RV continued to grind his/her teeth. On at least one occasion RV was observed outside on the porch for over two hours without food or water. RV's mouth was ""white and foamy."" The licensee failed to provide appropriate care to RV. The failure is violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +CO12045,501863,AFH,4/18/2012,"A renewal visit was conducted at the licensee_x001A_s adult foster home (AFH) on April 18, 2012. During the renewal the licensor found that a required smoke detector was not functional, and upon further inspection discovered that the battery had been removed from the smoke detector. The licensee failed to provide a safe environment. The licensee_x001A_s failure is a violation of Oregon Administrative Rules.",0,250,,, +CO13144,501863,AFH,11/21/2013,See Civil Penalty #AFHCP14-026,3,1150,,, +GP135263,501863,AFH,12/3/2013,"On or about December 3, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to administer a medication as ordered to Reported Victim (RV). RV was ordered to receive a topical compound three times daily. The topical compound bottle instructs to administer three to four times daily. Reported Perpetrator #2 (RP2) initialed the medication administration record (MAR) as having administered the medication four times daily. RP1 and RP2 state that RV was being administered the compound three times daily. The MAR for the month of November 2013, showed that a suppository medication was not initialed on 11/26/13 and 11/28/13. The licensee failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +GP135116,501863,AFH,11/19/2013,"On or about November 19, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV has physician orders to check and document RV's blood sugar testing during the am, pm and before bed. Home care notes for RV dated 07/09/2013 note that RP1 did not check RV's blood sugar readings as per physician instructions dated 07/01/2013. RV's blood sugar log dated 07/2013 was blank, 08/01/2013 through 08/31/2013 blood sugar stats were blank, 09/01/2013 to 09/30/2013 blood sugars were blank. RP1 acknowledged RV's records are a ""mess"" and not up to date. Witness #1 (W1) observed a box of plastic wrap sitting on a table in RV's bedroom. Reported Perpetrator #2 (RP2) stated that RP1 and RP2 use barrier cream and plastic wrap on RV every night to stop bed sores and/or skin breakdown. RP2 acknowledged there are no physician orders to use plastic wrap on RV. The licensee failed to follow physician orders and failed to obtain physician orders as required. The failures are a violation of Oregon Administrative Rules.",2,,,, +GP150162,501863,AFH,2/6/2015,"It was reported that on or about February 6, 2015, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee's failures are a violation of Oregon Administrative Rules (OARs) are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +ES153367,501953,AFH,10/23/2015,"RV1 was a resident of the adult foster home and required assistance with bathing, grooming and personal hygiene. RP was responsible for ensuring that RV1 received appropriate care and services. On October 23 and October 29, 2015 RV1's toenails were visibly curled and too long for RV1 to comfortably wear shoes. When interviewed, RP stated that he/she knew that the individual who regularly trimmed RV1's nails would be unavailable for an extended period of time. RP also failed to follow up on a referral to a podietry clinic for RV1. On October 23 and October 29, 2015 RV1's fingernails were observed to be ragged and long with dark crusted matter under the nail beds. RP stated that soap never touches RV1's hands because RV1 will not allow it. RV1's bedroom floor and bedding were observed to be dirty and stained. The facility failed to provide appropriate care and services to RV1. The facility's failure is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS121852,502078,AFH,12/7/2012,"On or about December 7, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV's careplan states that RV is a fall risk. RV falls frequently and bruises easily. RV's narration included recent documented falls on 12/1/12 and 12/4/12. RV expressed h/h fear of falling. RP1 has not taken proper precautions to help prevent RV from falling. RV's careplan states that RV requires assistance in bathing and that RV is to be bathed 1-2 times per week. RP1 does not provide assistance to RV when RV is bathing. The medication administration record (MAR) for RV was not initialed as required on 12/12/12. Multiple medications were not initialed as required for the date of 12/11/12. RV's MAR was not current and complete as required. An anti-psychotic medication, and heart medication that was ordered by RV's physician was not included on the MAR. The licensee failed to provide appropriate care to RV. The failures are a violation of Oregon Administrative Rules.",2,0,,, +MS121991,502078,AFH,12/24/2012,"On or about December 24, 2012, it was alleged that Reported Perpetrator (RP) failed to administer ordered medication to Reported Victim (RV). On 11/7/12 RV's physician prescribed two fluid retention medications for RV. As of 12/31/12 RV had not received the fluid retention medication as evidence by RV's medication administration record (MAR). On 11/7/12 RV was ordered to have h/h blood sugars tested three times daily before meals. As of 12/31/12 RV had not had h/h blood sugar tested three times daily per RV's MAR. On 11/7/12 RV's primary physician ordered RV to receive a sliding scale before meals. As of 12/31/12 RV had not received sliding scale per RV's MAR. The licensee failed to administer RV's medications as ordered. The failures are a violation Oregon Administrative Rules.",2,0,,, +MS133306,502078,AFH,5/24/2013,"On or about May 24, 2013, Reported Perpetrator #2 (RP2) transported Reported Victim (RV) to his/her medical appointment. RP2 had not had a valid driver license since 2004. Upon RP2_x001A_s arrival at the medical facility Witness #2 (W2) observed RP2 slurring his/her speech and smelled alcohol on RP2. W2 learned that RP2 had transported RV to the medical appointment and contacted law enforcement. + + + +The police report dated 5/24/2013 notes that RP2 showed clear signs of intoxication and impairment and had a faint smell of alcohol. RP2 was observed to be slurring his/her words, had dilated pupils, and was showing signs of being on a depressant and a stimulant. The police report notes that RP2 stated he/she had used methamphetamine and _x001A_was jacked up_x001A_ and decided to start sipping on alcohol all day. A Drug Recognition Evaluation was performed on RP2 which indicated impairment on a controlled substance/stimulant. RP2 was cited and released for Driving Under the Influence of Intoxicants. The licensee failed to provide appropriate transportation for RV_x001A_s medical appointment as required. The licensee_x001A_s failure is a violation of Oregon Administrative Rule and constitutes abuse. UPDATE: FOD sent and email sent to AR requesting that the aging process begin 10/09/2013",3,400,,,Neglect +MS133320,502078,AFH,5/1/2013,"On or about May 1, 2013, it was alleged that Reported Perpetrator (RP) failed to administer ordered medication to Reported Victim (RV). At least eight medications for RV's medication administration record (MAR) for the month of May were ommitted. RP acknowledged that RV did not receive the medictions ommitted from RV's may MAR. It was determined that the licensee failed to administer ordered medication to RV. The failure is a violation of resident rights and constitutes abuse.",2,,,,Neglect +WB154099,502122,AFH,12/9/2015,"It was reported that on or about December 9, 2015, Licensee failed to provide a safe environment for RV1. Licensee failed to transfer RV1 with the required amount of people resulting in bruising, pain and RV1 being transferred to the hospital. Wrongdoing on the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +RD118632,502154,AFH,11/26/2011,"On November 26, 2011, Resident #1 (RV1) and Resident #2 (RV2) were in the kitchen/dining area of the adult foster home. RV2 became angry at RV1 over a sandwich. RV2 pulled RV1 out of his/her chair by the hair and punched RV1 on the side of the head several times. RV1 escaped the altercation and ran to RV1's room, locked the door, and called law enforcement. RV1 had a handful of hair pulled out during the incident and was emotionally shaken. RV2 has a known history of angry outbursts and unpredictable behavior. Police have responded more than once to the facility address due to RV2 becoming out of control. The facility failed to appropriately assess and intervene when RV2's behavior escalated in the months prior to this occurrence, resulting in harm to RV1. This failure is a violation of residents rights, is considered neglect and constitutes abuse.",3,400,,,Neglect +BH147411,502174,AFH,6/15/2014,"On or about June 16, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). Witness #1 (W1) found RV sitting in his/her feces at the adult foster home (AFH). W1 contacted emergency personnel and RV was transported to the hospital for treatment. While at the hospital RV was found to have multiple lesions to the sacral area. The licensee failed to provide appropriate care to RV. The failure is a violation of resident rights and constitutes abuse.",2,,,,Neglect +MS117975A,502205,AFH,9/15/2011,"Reported Victim #2 (RV2) was left unattended outside and walked away from the Adult Foster Home on June 1, 2011. RV2 was discovered on the ground down the street by a neighbor and was transported to the hospital by ambulance. Care plan for RV2 states RV2 is unsteady on feet, needs supervision in all areas and staff is to watch RV2 constantly. The facility failed to provide a safe environment. The failures are violation of resident rights, are considered neglect of care and constitute abuse",3,400,,,Neglect +MS117975B,502205,AFH,9/15/2011,"On or about September 15, 2011, it was alleged that Reported Perpetrator (RP) failed to assess and intervene when Reported Victim #1 (RV1's) condition changed . It was determined that the licensee failed to adequately care plan surrounding RV1's falls.",2,0,,, +CO14192,502205,AFH,9/22/2014,"On September 22, 2014, the licensor conducted and annual inspection at the licensee's adult foster home (AFH). Upon arrival caregiver RB and licensee were the only caregivers present. During the visit it was discovered the licensee's criminal background check expired 9/9/2014 and caregiver RB's criminal background check expired 9/16/2014. The licensee and caregiver RB were working unsupervised without a cleared criminal background check. The licensee's conduct constituted a failure to provide a safe environment. The failure is a violation of Oregon Administrative Rules. FOD E-MAILED TO LLA AND PROVIDER",3,500,,, +BH118714A,502224,AFH,12/6/2011,"On December 6, 2011, at approximately 9:00 AM, While Reported Perpetrator #2 (RP2) was assisting RV1 to the bathroom, RV1 became non-responsive, was not breathing and did not have a pulse. RP2 failed to contact emergency personnel in a timely manner and did not attempt to resuscitate RV1 as he/she thought RV1's living will was a do not resuscitate order (DNR). RP2 stated that he/she did not know what to do when RV1's condition changed. Licensee's failures are a violations of resident rights, are considered neglect and constitute abuse.",3,750,,,Neglect +BH118714B,502224,AFH,12/6/2011,"It was reported that on or about December 6, 2011, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee placed a recliner in RV1's room that had some missing parts and as a result had sharp edges. RV1 chose to slepp in the recliner and scrapped his/her legs on the sharp edges of the chair, resulting in lacerations to his/her legs. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES117507,502268,AFH,7/14/2011,"The facility medication records were reviewed on or about July 2011. The investigation discovered that on three occasions on or about July 13 and July 14, 2011, Reported Perpetrator #2 (RP2) failed to document the amount of medication given or immediately initial Resident #1's Medication Administration Record (MAR) to accurately reflect that the medication had been dispensed. On or about July 3, 2011, RP2 initialed that a medication had been administered but did not document what dosage was dispensed. On or about July 12, 2011, Reported Perpetrator #1 (RP1) failed to document and initial Resident #1's MAR to indicate that medication was administered and at what dosage. On or about July 4, 2011, RP1 incorrectly gave Resident #1 four units of a medication instead of six units. Witness #1 reported that on or about July 14, 2011, he/she observed Reported Perpetrator #3 (RP3) attempt to complete Resident #1's MAR for a medication dispensed by RP2 during an earlier shift. The investigation concluded that the facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",2,0,,, +ES121688,502532,AFH,11/23/2012,"It was reported that on or about November 23, 2012, Licensee failed to maintain a safe medication administration system. On November 23, 2012, Reported Perpetrator #2 (RP2) placed medication for Resident #1 (RV1) and Resident #2 (RV2) in separate paper cups and placed the cups on the table where RV1 and RV2 were seated. RP2 turned away and RV1 mistakenly took the cup of medications intended for RV2. Licensee's failures are a violation of Oregon Administrative Rules (OARs) is considered neglect of care and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +CO13138,502726,AFH,11/18/2013,"An unannounced monitoring visit was conducted at licensee_x001A_s adult foster home (AFH) on November 18, 2013. The licensor arrived at approximately 11am and determined there was no caregiver on duty. The licensor contacted the licensee by telephone at approximately 11:30am. The licensee acknowledged that he/she had left the AFH _x001A_just before 11am_x001A_. The local licensing authority remained at the facility until a substitute caregiver arrived at approximately 11:40am. The facility failed to have a qualified caregiver present and available in the AFH at all times, twenty-four hours per day, seven days per week.",3,250,,, +ES116339A,502819,AFH,11/1/2010,"On or about February 14, 2011, it was reported that the Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee failed to assist RV1 with bathing one time per week as indicated on his/her care plan, and failed to empty RV1's bedside commode in a timely manner. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee had been substantiated.",2,0,,, +ES116339B,502819,AFH,11/1/2010,"On or about February 14, 2011, it was reported that the Licensee failed to protect Resident #1 (RV1) from threats of punishment, humiliation or harassment. Licensee told RV1 he/she would put mittens on RV1 if he/she did not stop scratching. Additionally, Licensee intimidated RV1 by telling him/her to get back in his/her room when RV1 needed to use the bathroom. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES116339C,502819,AFH,11/1/2010,"It was reported that on or about November 1, 2010, Licensee secluded Resident #1 (RV1) to His/her room and restricted RV1's communication with others by placing a baby monitor in his/her room when RV1 was visiting with family members. Licensee's actions are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES116339D,502819,AFH,11/1/2010,"It was reported on or about February 14, 2011, that the Licensee had used one of Resident #1's (RV1) medications as a chemical retraint to control his/her behavior. RV1's medication was perscribed on a as needed (PRN) basis. RV1's medication administration records (MAR) indicated that the Licensee administered the medication as a regular scheduled medication four times daily during the months of October, November and January 2010. Licensee's actions are a violation of Ortegon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES116339E,502819,AFH,11/1/2010,"It was reported that on or about November 1, 2010, Licensee failed to protect Resident #1 (RV1) from wrongful taking. When Witness #4 (W4) went to pick RV1's belongings up from Licensee's after moving to a new location, there were 3 items that belonged to RV1 that were missing. Licensee's failures are a violation of resident right and constitute financial exploitation. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +ES116339F,502819,AFH,11/1/2010,"It was reported that on or about November 1, 2010, Licensee failed to Administer Resident #1's (RV1) pain medication as ordered. Pain medication patches were not properly given as evidence by RV1 having 3 patches on when he/she went to the medical clinic. Licensee failures are a violation of Oregon Administrative Rule. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES133854B,502819,AFH,7/19/2013,"It was reported that on or about July 19, 2013, Licensee failed to maintain a safe environment for all residents. Upon entering the facility on July 19, 2013, the investigator smelled a very strong odor of animal urine while knocking on the door and the smell was greater once the investigator entered the facility causing him/her to feel nauseous and made his/her eyes water. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +ES134227A,502819,AFH,8/16/2013,"It was reported that on or about August 16, 2013, Licensee failed to protect Resident #1 (RV1) from involuntary seclusion. Wrongdoing on the part of the Licensee was substantiated.",1,,,,Involuntary Seclusion +ES134227B,502819,AFH,8/16/2013,"It was reported that on or about August 16, 2013, Licensee failed to provide appropriate care to Resident #1 (RV1). While at Licensee's Adult Foster Home (AFH) the investigator observed RV1 to be aggitated and uncomfortable. Rv1 had unclean hair and had what appeared to be fecal matter on his/her hand and fingers as well as brown matter under his/her fingernails. Investigator also observed brown matter on RV1's clothing. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MS121167C,502892,AFH,9/26/2012,"On or about September 26, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), and Reported Victim #5 (RV5). It was determined Reported Perpetrator #2 (RP2) left the facility on August 25, 2012, with no other qualified care giver present for at least two hours. The licensee failed to provide a safe environment for RV1, RV2, RV3, RV4, and RV5. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RD134022,503015,AFH,7/3/2013,"On or about July 3, 2013, Resident #1 (RV) moved into Reported Perpetrators (RP) Adult Foster Home (AFH). RV arrived at the AFH with medication to last him/her approximately a week. Between the dates of 7/05/2013 and 07/23/2013 RV ran out of multiple medications that included medication for chronic heartburn, anxiety, narcotic pain medication and non-narcotic pain medication. As a result, RV experienced increased anxiety and increased pain. Additionally RV ran out of a water retention medication. RV was administered several doses of water retention medication from a bottle of the same medication that had been prescribed to a deceased resident. The licensee failed to administer ordered medication to RV. The licensee_x001A_s failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,400,,,Neglect +SV118365,503022,AFH,10/29/2011,"On or about November 3, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. It was determined that Reported Perpetrator #2 (RP2) made demeaning comments to RV. The licensee failed to protect RV from inappropriate comments.",2,0,,, +MM118513,503131,AFH,11/3/2011,"It was reported that on or about November 3, 2011, Licensee failed to provide a safe environment for Resident #1 (RV1). Reported perpetrator #2 (RP2) was demeaning toward RV1 by evidence of his/her body language and tone of voice. Licensee's failure to provide a safe environment for RV1 is a violation od Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO11079,503256,AFH,4/26/2011,"Licensee failed to have handrails on exterior stairs, failed to have a barrier around the pool and failed to keep pool covered, failed to have an appropriately sloped ramp, failed to use simple locking hardware on doors and failed to keep egresses unobstructed.",3,0,,, +MS121548,503256,AFH,11/7/2012,"On or about November 7, 2012, between approximately 3:00PM to 3:15PM, staff at licensee_x001A_s adult foster home (AFH) noticed Resident #1 was missing from the home. Resident #1 is cognitively impaired and had a history of wandering away from the AFH. Resident #1_x001A_s Care Plan dated September 5, 2012 indicates that Resident #1 _x001A_wanders_x001A_, _x001A_tries to get out of the home without aim or destination_x001A_ and _x001A_tries to climb fences_x001A_. During the course of the investigation Witness #2 reported that licensee acknowledged to him/her that facility staff were aware of Resident #1_x001A_s _x001A_proclivity for escaping as [Resident #1] had walked away from the facility before._x001A_ Update: FOD completed for 4/3/14, email sent to AR requesting they begin the aging process. + + + +At approximately 3:55PM, Resident #1 was found in the yard of a homeowner approximately 1.45 miles from licensee_x001A_s adult foster home. Resident #1 was found covered with mud, thistles and burrs. The homeowner notified law enforcement who took Resident #1 to the local hospital. Neither the licensee nor licensee_x001A_s staff had notified the local police department that Resident #1 was missing from the AFH, and the police department called several adult foster homes before finding the one at which Resident #1 resided. + + + +Despite the fact that Resident #1 had left the home without supervision several times prior to this incident, and had a history of such behavior, an alarm bell was only located on the front door. The back door did not have an alarm bell and the gate in the backyard did not have an alarm. Licensee staff was not immediately aware that Resident #1 had eloped. + + + +Licensee failed to ensure Resident #1 received appropriate care and oversight. Licensee_x001A_s failure to put interventions in place to address Resident #1_x001A_s history of wandering resulted in Resident #1 suffering moderate harm and placed at risk of serious harm. This failure is a violation of resident rights, is considered neglect and constitutes abuse",3,400,,,Neglect +MS150767B,503256,AFH,4/1/2015,"It was reported that on or about April 1, 2015, Licensee failed to provide appropriate care to Resident #1 (RV1). RV1 obtained a rash while in Licensee's care. RV1 did not receive appropriate care for the rash while in Licensee's care. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +MV105861A,503308,AFH,10/1/2010,"On or about August 2010 and September 2010, Licensee insulted, yelled at and intimidated residents creating fear and anxiety.",3,0,,,Verbal/Mental abuse +MV118671A,503308,AFH,11/20/2011,"On or about December 1, 2011, Licensee failed to provide appropriate care for Resident #1 (RV1). Licensee failed to seek medical care for RV1 despite numerous indications that RV1's health condition was declining. Licensee's failures are a violation of Oregon Administrative Rules (OARs), are considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +CO13092,503308,AFH,7/3/2013,"On or about July 3, 2013, the licensor conducted a renewal inspection at the licensee's adult foster home (AFH). During the inspection the licensor discovered a smoke detector was not installed in Resident #1's bedroom, the licensee's bedroom, and the hallway adjoining the licensee's bedroom. The licensee failed to install all required smoke detectors. The licensee's conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. UPDATE: FOD sent and email sent to AR to begin Aging Process 10/09/2013",3,750,,, +MV147118A,503308,AFH,5/16/2014,"It was reported that on or about May 16, 2014, Licensee failed to provide Reported Victim #1 (RV1) with as needed pain medication when requested. RV1 lived in Licensee's Adult Foster Home (AFH) for 10 days. RV1 arrived to the AFH with 10 tabs of medication #1 and 38 tabs of medication #2. When RV1 moved out he/she did not have to correct amount of medications. Licensee's failures are a violation of Oregon Administrative Rules is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +NB105803A,503311,AFH,12/7/2010,,0,0,,, +NB105803B,503311,AFH,12/7/2010,,4,0,,,Verbal/Mental abuse +HB118548,503398,AFH,11/29/2011,"It was reported that on or about November 29, 2011, Licensee failed to provide Resident #1 (RV1) with the appropriate care and services. RV1 experieneced a decline in health condition and a significant increase in his/her care needs. Licensee failed to notify RV1's physician and failed to provide appropriate care to RV1. As a result of not receiving the appropriate care and services, RV1 was transferred to the hospital for treatment. Licensee's failures are a violation of resident rights, is cinsidered neglect and constitute abuse.",4,750,,,Neglect +HB148490A,503398,AFH,9/11/2014,"On or around 9/11/14, Adult Protective Services (""APS"") received an allegation that the facility failed to provide a safe environment. During the course of the investigation, APS found that RV has memory impairment and has attempted to wander from the facility several times. The facility's service plan did not include interventions regarding RV's wandering from facility without assistance. Although the facility placed an alarm on RV's bedroom door at night, there was no alarm system used during the day. On 9/10/14, RV was found walking on the side of the road wearing pajama bottoms, a t-shirt, and barefoot. RV was unable to recall where he/she lived when assistance was provided. The facility failed to provide a safe environment for RV, which allowed RV to wander from the facility and exposed RV to potential for serious harm. This failure is a violation of Oregon Administrative Rule and resident rights, is considered neglect, and constitutes abuse.",3,200,,,Neglect +HB116335,503596,AFH,2/10/2011,"Resident #1 (RV1) moved from this adult foster home to another facility. After RV1 moved, some of his/her prescriptions were delivered to the home. RV1's whereabouts were unknown so Reported Perpetrator #2 (RP2) was instructed to destroy the medications. RP2 destroyed all but one prescription. RP2 gave that prescription to another person who had a current prescription for the same medication. RP2 failed to properly dispose of the unused medication.",2,0,,,Financial abuse +HB151577B,503723,AFH,6/12/2015,"It was reported that on or about June 12, 2015, Licensee failed to maintain an adequate medication administration system for Resident #1. Resident #1 wanted to leave the facility with Witness #2 and Licensee refused to give Resident #1 his/her medications. As a result of not having his/her medications Resident #1 suffered leg pain. Licensee's failures are a violation of Oregon Administrative Rules is considered neglect and constitutes abuse. Wrongdoing on the part of the License was substantiated.",2,,,,Neglect +RD135032,503728,AFH,9/14/2013,"On or about September 14, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from rought treatment. On or about 9/14/2013, RV was discovered on the floor of his/her bedroom. RP stated that RV has behaviors where RV will put him/her self on the floor or lay in bed and will not respond questions or verval stimuli but will respond to ""taps"" on the shoulder. RP stated that RV was not responding to any verbal stimuli so RP ""patted RV on the cheeks and back of head and patted RV on the behind."" When RV did not respond RP got a glass of water and ""sprinkled water on his/her cheek"" and RV responded by grimacing then smiling . RV's care plan dated 5/3/2013 does not note the behavior as described by the RP. The licensee failed to update care plan as required. The failure is a violation of Oregon Administrative Rules.",2,,,, +BO148584,503728,AFH,8/14/2014,"On or around 8/14/14, Adult Protective Services received a complaint that the facility failed to provide a secure environment for the reported victim (RV). RV's care plan noted that RV wandered and would attempt to leave the facility. RV had previously left the facility on several occasions and did so again, without caregivers, during the incident investigated. Facility did not have alarms on outside doors to notify of resident's attempts to leave the home, as required by OAR. Instead, facility originally had childproof locks on the front door (removed because they were not compliant with Oregon Administrative Rule (OAR)). Facility then placed a walker and wheelchair in the hallway, which became a barrier to exit. Facility's failure to provide a safe environment exposed resident to potential harm and is a violation of resident rights, constitutes neglect, and is considered abuse. FOD snet 12/8/14 to provider and copy to LLA",3,200,,,Neglect +CO11067,503814,AFH,1/26/2011,"substantial non-compliance, failed to protect residents from verbal and physical abuse and exploitation",4,0,Not Substantiated,Substantiated,Physical Abuse +CO11069,503814,AFH,1/26/2011,"failed to have appropriate, timely and accurate documentation, failed to have qualified caregivers, failed to have approved criminal history checks for all subject individuals, failed to provide a safe environment, failed to have a safe medication administration system, and failed to protect residents from abuse",4,0,Not Substantiated,Substantiated,Physical Abuse +MM116175,503814,AFH,12/19/2010,"On or about December 17, 2010, Licensee sent 3 unapproved caregivers into Resident #1's (RV1) room to clean it. None of the 3 caregivers had completed their criminal record checks. RV1 became angry and started fighting with the caregivers. The caregivers did not comply with the careplanned directions for dealing with RV1 when he/she became aggressive. This home has since closed.",2,0,,, +MM116968,503814,AFH,5/8/2011,"On May 8, 2011 Resident #1 (RV1) purchased some beer and took it back to the adult foster home. Reported Perpetrator #2 (RP2) removed the beer without RV1's permission and an argument ensued. RP2 pushed RV1's walker backward until RV1 fell into his/her chair. This home has since closed.",2,0,Not Substantiated,Substantiated,Physical Abuse +CO12102,503955,AFH,8/29/2012,Caregiver without an approved criminal records check was left alone with residents.,3,250,,, +CO15183,503974,AFH,9/1/2015,Unqualifed caregiver working alone in AFH.,3,250,,, +BR117290,504106,AFH,2/12/2011,"On February 12, 2011, Resident #1 fell in his/her bedroom and sustained an injury. Licensee did not seek medical treatment for Resident #1 until after he/she had further declined on February 13, 2011. Licensee failed to exercise reasonable precautions and seek timely medical treatment for Resident #1 which resulted in continued harm to Resident #1.",3,,,,Neglect +RS118221,504116,AFH,10/9/2011,"On or about October 9, 2011, Resident #1 (RV1) found Reported Perpetrator #2 (RP2) unconscious, on the floor next to the front door at the licensee_x001A_s Adult Foster Home (AFH). RV1 contacted 911 at approximately 7:30am. RP2 was the only caregiver on duty at the time of the incident. It was determined that RP2 had overdosed on medication. Reported Perpetrator #1 (RP1) was notified of the situation by witness #4 (W4) who had arrived at the AFH after emergency personnel was contacted. According to the Patient Care Report, RP1 informed emergency personnel that RP2 had been talking about committing suicide with pills for the past week. + + + +Care plan for Resident #2 (RV2) states that RV2 is unable to transfer and uses a wheelchair for mobility. Care plan for Resident #3 (RV3) states that RV3 cannot transfer without assistance, is full assist with Activities of Daily Living (ADL_x001A_s), and is dependent with emergency exiting. The licensee failed to provide a safe environment which placed RV1, RV2, RV3, and RV4 at risk for serious harm. The failure is a violation or Oregon Administrative Rule and constitutes abuse.",0,400,,,Neglect +RB135432,504116,AFH,12/19/2013,"On or about December 20, 2013, it was alleged that Reported Perpetrator (RP) failed to intervene when Reported Victim's (RV) condition changed. RV's memory is poor due to his/her condition. RV had a history of wandering. On 11/09/13 RV was seen walking down a busy highway. A concerned citizen contacted law enforcement. When law enforcement arrived RV was confused. RV was transported back to the adult foster home without injury. The facility documented concern over RV's wandering and poor judgement on 09/2012. The licensee failed to intervene when RV's condition changed. The failure is a violation of Oregon Administrative Rules.",2,,,, +JG120168,504138,AFH,1/10/2012,"On or about January 10, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). It was determined through interviews that RV2 sometimes assists RP with the medication administration at the facility. The facility failed to provide a safe medication administration system. The failure is violation of Oregon Administrative Rule",0,0,,, +CO11142,504143,AFH,10/12/2011,"The licensor made a home visit to the licensee_x001A_s Adult Foster Home on October 12, 2011 in response to a complaint made on October 11, 2011. The licensor discovered that occupant (CB) is over the age of 16 and did not have an approved criminal records check and had been living in the Adult Foster Home for roughly three weeks. It was also discovered that relative (AC) who is over the age of 16, was an occupant in the Adult Foster Home from 2007-2011, and did not have an approved criminal records check. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,200,,, +HB121239,504143,AFH,10/4/2012,"On or about October 4, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV has a history of elopement. RV eloped from the facility sometime after 11:30pm. RV was discovered sitting down on the ground by a lamp post. Law enforcement responded at 12:20am, RV was found to be disoriented. Law enforcement transported RV back to the licensee's adult foster home. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV116223,504212,AFH,1/24/2011,"On or about January 24, 2011, Licensee yelled at Resident #1 and called him/her a profane name.",2,,,,Verbal/Mental abuse +HB129519,504273,AFH,3/14/2012,"It was reported that on or about March 14, 2012, Licensee failed to provide a safe medication administration system. Facility staff failed to ensure that Resident #1 (RV1) was ingesting his/her medication when administered. Facility staff failed to contact RV1's doctor regarding his/her refusal to take medications. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB120533,504273,AFH,7/15/2012,"It was reported that and or about July 15, 2012, Licensee failed to provide an adequate medications system. Licensee failed to ensure that Resident #1 received the correct dose of medication. Resident #1 had a physician order to receive 10mg tablet of medication. On July 15, 2012, Reported perpetrator #2 (RP2) had administered a 5mg tablet of medication to Resident #1. Licensee failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB121123,504273,AFH,9/21/2012,"It was reported that on or about September 21, 2012, Licensee failed to protect residents from emotional abuse. Reported perpetrator #2 (RP2) did not get along with Resident #1 (RV1). RP2 indicated that he/she had a problem with RV1 because RV1 was rude. RP2 threw RV1's clothes at him/her and told RV1 to get dressed. Additionally, RP2 would take Resident #2's (RV2) radio away as discipline for wetting his/her bed. Licensee's failures are a violation of Oregon Administrative Rules and constitutes emotional abuse. Wrongdoing on the part of the licensee was substantiated.",2,0,,,Verbal/Mental abuse +HB132873,504273,AFH,4/8/2013,"It was reported that on or about April 8, 2013, Licensee failed protect Resident #1 from theft of medications. On April 7, 2013 at 8:00 AM, there were two doses of Resident #1's medication left on the first medication card. Witness #2 (W2) administered a dose to Resident #1 at 8:00 AM, and one dose was remaining on the first card. At Some point between 8:00 AM and 1:00 PM on April 7, 2013, the last dose of medication on the first card went missing. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +HB133872,504273,AFH,7/22/2013,"It was reported that on or about July 22, 2013, Licensee had verbally abused Resident #1 (RV1). Licensee admitted to saying to RV1 during an argument "" remember, I could hit you harder"". Licensee's failures are a violation of Adult Foster Home (AFH) Oregon Administrative Rules (OARs), and is considered verbal/mental abuse.",2,,,,Verbal/Mental abuse +HB134045,504273,AFH,8/4/2013,"It was reported that on or about August 4, 2013, Licensee failed to provide appropriate care for Resident #1. Licensee failed to have a system in place to ensure Resident #1 returns safely from walks. Licensee did not have any safe-guards to protect Resident #1 from leaving the facility in an altered state of mind due to a medical condition. Licensee failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +HB134898,504273,AFH,10/31/2013,"It was reported that on or about October 31, 2013, Licensee failed to maintained an adequate medication system. Resident #1 (RV1) returned to Licensee's Adult Foster Home (AFH) on October 18, 2013, after an extended stay outside of the AFH for medical treatment. On October 18, 2013, RV1 received a order for a prescription medication. RV1's prescription medication was not filled or received until October 30, 2013. Licensee's failures are a violation of Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +KF116454,504358,AFH,2/28/2011,"On or about March 3, 2011, it was reported that the Licensee failed to seek timely medical treatment for Resident #1 (RV1). On February 28, 2011 RV1 had sustained a fall, RV1 complained of pain from March 1, 2011 through March 4, 2011. Licensee did not contact RV1's physician until March 4, 2011. It was found that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO14061,504426,AFH,10/31/2013,Revocation not needed - not moving forward based on DOJ advice,4,,,, +RD129765A,504659,AFH,11/20/2010,"On or about November 20, 2010, it was reported that during the month of February 2011 at approximately 8:00 PM, Reported perpetrator #2 (RP2) was attempting to get RV1 ready for bed. RV1 refused to take his/her shirt off and put night clothes on so RP2 cut RV1's shirt off with a pair of scissors. RP2's actions are a violation of resident rights. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RD129765B,504659,AFH,11/20/2010,"It was reported that on or about February 14, 2012, Licensee failed to care paln appropriately related to Resident #1's (RV1) ongoing behaviors. Reported Perpetrator #3 (RP3) took RV1 to his/her room to change his/her brief before RV1 joined the other residents at the table for dinner. RV1 became combative with RP3 while he/she was attempting to change RV1's brief. RP3 left the room to allow RV1 time to calm down, when RP3 returned RV1 continued to be combative with RP3, RP3 told RV1 it would be best if he/she just went to bed for the evening. RP3 removed RV1's side chair, wheel chair and walker, resulting in involuntary seclusion. Wrongdoing on the part of the Licensee was substantiated.",2,0,Not Substantiated,Substantiated,Involuntary Seclusion +MS150450,504667,AFH,3/3/2015,"On or about March 3, 2015, Adult Protective Services (APS) received a complaint that the facility failed to protect residents from physical harm. During the course of the interview, it was determined that RV1 and RV2 had multiple instances where RV2 would place his/her walker in front of the bathroom door, blocking RV1 from exiting the bathroom, which would upset RV1. RV2 had dementia and RV2's care plan states that RV2 was to observed for any aggressive behavior. On or about March 3, 2015, both RV2 and RV1 were walking towards each other, from opposite directions, and met near the doorway near the dining room. RV1 pushed his/her walker into RV2's walker because RV2 could not move. RV2's right hand was pinched between the wall and walker and swelling was noted on RV2's right knuckle. RV2 also had a bruise on his/her right hand and a red mark on his/her right cheek. RV1 was issued involuntary moveout notice, as this was the third outburst from RV1. Facility's failure to timely update care plans regarding behaviors is a violation of Oregon Administrative Rule.",2,400,,, +HB133927,504800,AFH,7/26/2013,"On or about July 26, 2013, it was alleged that Reported Perpetrator (RP) failed to administer an ordered medication to Reported Victim (RV). On or about 7/25/2013 Witness #1 (W1) observed RV to be in substantial pain and recommended that RV's pain medication be increased. W1 communicated this recommendation to RP and contacted RV's medical doctor. RP received an updated medication order via fax the afternoon of 7/25/2013 from RV's medical doctor. RP did not receive the correct dose of pain medication until the evening of 7/26/2013. RV states he/she was in ""terrible pain"" until the medication change was made. The licensee failed to administer an ordered medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO11033,504817,AFH,6/22/2010,Caregiver was former Licensee with substantiated abuse by neglect resulting in severe decubitus ulcer.,4,0,,, +HB132271A,504817,AFH,1/29/2013,"On or about January 29, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from inappropriate verbal comments. RP would ""scream and holler"" at RV1 stating that RV1 was not going to the bathroom fast enough. RP would scream at RV1 to ""hurry up"" when RV1 was on the toilet. As a result RV1 felt degraded, upset, and ""dreaded"" having to go to the restroom. Witness #3 (W3) stated that W3 has heard RP yell at RV2. It was determined that the licensee failed to protect RV1 and RV2 from inappropriate verbal comments. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Verbal/Mental abuse +MS118176A,504871,AFH,10/10/2011,"On or about October 10, 2011, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3) from loss of medication. It was determined that RV1 and RV2 were missing medications. Licensee failed to provide a safe medication administration system.",2,0,,, +MS118176B,504871,AFH,10/10/2011,"On or about October 10, 2011, it was alleged that Reported Perpetrator (RP) failed to obtain a medical order prior to providing medical care to Reported Victim #3 (RV3). It was determined that RP did not consult with a medical professional or obtain a doctor's order prior to treating RV3's sores. Licensee failed to obtain a medical order.",2,0,,, +MS118176D,504871,AFH,10/10/2011,"On or about October 10, 2011, it was alleged that Reported Perpetrator (RP) failed to administer medications as ordered to Reported Victim #1 (RV1). It was determined that RP did not follow they physician's orders for a narcotic pain medication for RV1 on September 1, 2011; September 3, 2011; and September 30, 2011. Licensee failed to administer medication as ordered.",2,0,,, +MS118176E,504871,AFH,10/10/2011,"On or about October 10, 2011, it was alleged that Reported Perpetrator (RP) failed to maintain an accurate medication record for Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3). It was determined that RP failed to update the medication administration record for RV1. Licensee failed to to keep medication record current and accurate.",2,0,,, +MF120653,504871,AFH,7/29/2012,"On or about July 29, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim (RV). It was determined that RP1 terminated Reported Perpetrator #2 (RP2). RP1 did not request RP2's keys to medication cabinet. After RP2 was terminated RP2 went to the medication cabinet and was attempting to administer RV's narcotic pain medication. After RP2 left the facility, it was discovered that two of RV's narcotic pain medication were missing. The licensee failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered financial exploitation, and constitutes abuse.",2,0,,,Financial abuse +CO12085,504879,AFH,7/20/2012,"Non-renewal based on suspension of July 31, 2012 (provider qualifications, fire life safety) and lack of financial resources. Home closed on 7/31/2012",3,0,,,Neglect +CO11020,504929,AFH,1/13/2011,,3,0,,, +ES116254,504929,AFH,1/31/2011,"On or about January 13, 2011, W1 and W2 were in a physical altercation at Licensee's that resulted in the arrest of W1. Neither W1 or W2 were supposed to be at the Adult Foster Home due to their criminal records.",2,0,,, +CO11137,504931,AFH,4/25/2011,"A licensing renewal visit was conducted at Licensee_x001A_s Adult Foster Home (AFH) on April 25, 2011. During this visit the licensor discovered that the smoke alarm in the hallway and in the provider_x001A_s bedroom was not functional when checked",3,200,,, +CO14058,504931,AFH,3/17/2014,,2,250,,, +RB146465,504931,AFH,3/3/2014,"On 02/02/2014 Resident #1 (RV1) got out of bed and went to the restroom. RV1 missed the bed while trying to get back in and hit the end table and hurt his/her arm. RV1 remained on the floor all night until he/she was discovered by Reported Perpetrator (RP) the following morning. RV1 was on the floor for approximately eight to ten hours. + + + +RV1's care plan dated 05/09/2013 indicates that RV1 uses a walker and needs assistance with mobility and transfer. Under night time needs, it states that caregivers need to listen for noise at nighttime in case RV1 falls down when using the restroom. Under medical concerns it notes that RV1 is a falls risk and cannot walk very far without panting. RV1 did not have a call system in his/her bedroom. RV1's progress notes dated 02/02/2014 state that a bedside commode has now been placed by RV's bed and RP will have RV1 open his/her bedroom door at bedtime so RP can hear RV1 call out. The licensee failed to provide a safe environment. The licensee's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse. UPDATE: Department received a letter on 11/24/2014 from the licensee stating that she withdraws her hearing request. FOP 12/5/14",3,400,,,Neglect +ES117035C,504932,AFH,5/20/2011,"It was reported on or about May 20, 2011, that Licensee sent Resident #2 (RV2) to his/her room as punishment. Resident #2 used inappropriate language while at the dinner table so Licensee sent RV2 to his/her room as punishment. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +CO14093,505393,AFH,4/29/2014,Licensee's presence on OIG and GSA exclusion lists.,3,0,,, +KF145645,505393,AFH,1/9/2014,"RV developed disruptive behaviors within three weeks of arriving at facility. The behaviors included throwing him/herself out of bed and down onto floor. RV injured his/her foot in one such fall and could no longer walk. RP tried to refer RV to end of life care, which was delayed. While awaiting end of life approval RP ordered restraints (gait belt) to be used to hold RV in a recliner used for RV to sleep in, to prevent RV from constantly getting up or throwing self out of bed. RV received skin injuries as a result of being immobilized by the restraint.",2,,,,Restraints +ES116419B,505762,AFH,2/16/2011,On or about 02/16/11 RP1 was reported to have yelled at RV1 and threaten to kick them out of the home. In an interview on 03/03/11 RV1 indicated RP1 yelled and threatened to kick him/her out of the home. On 05/03/11 W1 was interviewed and stated they had heard RP1 yell and scream at RV1. This conduct constituted a violation of Oregon licensing rules and constitutes abuse.,2,250,,,Verbal/Mental abuse +ES120833,505762,AFH,8/11/2012,"On or about August 11, 2012, at approximately 11:00am Resident #1 (RV1) wanted to go outside and sit in the sun at the licensee_x001A_s Adult Foster Home (AFH). RV1 was placed in a lounge chair outside. RV1 did not have the ability to get out of the lounge chair on his/her own. On that date the temperature outside was in the mid 80_x001A_s. Reported Perpetrator #2 (RP2) discovered RV1 to be unconscious and contacted paramedics at approximately 12:54pm. RV1 was checked on one time between 11:00am and 12:54pm by RP2. RV1 was transported to the hospital for further treatment. RV1 was diagnosed with metabolic encephalopathy likely due to mild non-exertional heatstroke, hyperthermia, and dehydration. RV1 also sustained a sun burn. Licensee failed to provide appropriate care to RV1. The licensee_x001A_s failure is violation of Oregon Administrative Rule and constitutes abuse. NOTE: 1/3/13 Final Order by Default completed. Sent to AR person to start aging process.",3,400,,, +ES121005B,505762,AFH,8/1/2012,"On or about August 1, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). During the time RP was on vacation, RV did not receive a bath. RP was on vacation for at least 10 days. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES121005A,505762,AFH,8/1/2012,"On or about August 1, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). RV received an order from h/h physician to change h/h blood pressure medication from 40mg to 20mg. RP went on vacation and did not change RV's blood pressure medication. RV did not receive h/h blood pressure medication for at least 5 days. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES120955,505762,AFH,8/20/2012,"On or about August 20, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). During a visit to RV's primary physician it was observed that RV had an area of h/her body that was not being properly cared for resulting in that part of the body worsening. RV's careplan was not updated to reflect the care required for that part of RV's body. RV's medication administration record was not accurate and up to date. RP1 did not report the change in RV's condition. The licensee failed to intervene when RV's condition changed. The failure is violation of Oregon Administrative Rules.",2,0,,, +CO13085,505762,AFH,4/8/2013,"An unannounced monitoring visit was conducted on April 8, 2013, at the licensee_x001A_s adult foster home (AFH) as a result of a complaint. The licensor discovered that Resident #1 was admitted on 4/5/2013 and required insulin injections. As of 4/8/2013 the licensee had not been delegated by a registered nurse to perform this skilled nursing task as required. The licensee failed to provide appropriate consultation for Resident #1. The licensee_x001A_s conduct constituted a failure to provide appropriate care and is a violation of Oregon Administrative Rules.",3,250,,, +ES132884A,505762,AFH,4/6/2013,"On or about April 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to administer ordered medication to Reported Victim (RV). RV was admitted to RP's facility on April 5, 2013. RP1 did not request or get RV's medications until 4/7/2013. The licensee failed to administer ordered medication to RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES132884B,505762,AFH,4/6/2013,"On or about April 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3) from inappropriate verbal comments. RP1 was witnessed telling an RV ""Do you want me to fuck you up"". RP1 was also witnessed calling RV1 a ""mother fucker"" and a ""jackass"". The licensee failed to protect RV1, RV2, and RV3 from inappropriate verbal comments. The failure is a violation of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +ES133677,505762,AFH,7/1/2013,"On or about July 1, 2013, it was alleged that the Reported Perpetrator (RP) failed to provide a homelike environment for Reported Victim (RV). RV previously smoked marijuana with Witness #2 (W2). RV was a long term marijuana user but was recently denied a request to get h/h medical marijuana card back. On 7/1/2013 W2 smoked marijuana in RP's bedroom. RV went ""berserk"" due to smelling the marijuana and had a verbal altercation with W2. The licensee did not address parameters for marijuana use with W2. The licensee failed to provide a homelike environment. The failure is a violation of Oregon Administrative Rule.",2,,,, +ES133613,505762,AFH,6/24/2013,"On or about June 24, 2013, it was alleged that Reported Perpetrator (RP) failed to appropriately care plan for Reported Victim (RV). On 6/23/2013 RV went outside of the facility to smoke as he/she normally does. Witness #3 (W3) observed RV fall and hit his/her head on the steps. W3 contacted 911 and notified RP. RP and W3 waited with RV until emergency personnel arrived. W3 stated that RV does fall a lot and RP acknowledged that RV ""falls a lot"". RV has a documented history of falls. RV's care plan was last updated 7/29/2009 and does not include any interventions relating to falls. RV sustained a head injury as a result of the fall. The licensee failed to adequately care plan related to falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES145897,505762,AFH,12/26/2013,"On January 26, 2014, at approximately 6:27am EMTs were dispatched to the licensee's adult foster home (AFH) in response to a reported fall. Upon arrival Witness #1 (W1) observed Resident #1 (RV) lying on the floor wearing a hospital gown that was soaked in urine and covered in feces. RV did not have any blankets on him/her and was shivering. Paramedics rolled RV over and discovered a large amount of feces on RV. W1 described the feces to be dried and crumbling and believed that the feces had been on RV for a considerable amount of time. It was W1's opinion that RV had been laying on the floor for approximately twelve hours. W1 also observed RV's bedding which was clean, free of any urine or feces and was made. W1 observed a laceration on RV's elbow that had been recently stitched; however, most of the stitches were ripped out and the wound appeared to be infected. Reported Perpetrator (RP) stated that RV had been picking the stitches out. W1 noted that RV had open sores on his/her buttocks, back and side. W1 stated that Reported Perpetrator (RP) could not provide W1 with RV's name or any medical information or health history for RV. W1 stated that RP presented as unconcerned for the welfare of RV. Witness #2 (W2) observed RV lying on the floor dressed in a hospital gown that was saturated with urine and feces. W2 noted that the feces had started drying out and was crusty. W2 observed a wound on RV's elbow that had been stitched; however, the majority of the stitches had been ripped out. W2 believed the wound to be infected. W2 also observed pressure ulcers on RV's buttocks and left side. RV was transported to the hospital for treatment. The nursing facility records and admission narrative note that upon arrival RV had several open areas from previous falls, areas all cleaned and re-dressed. + + + +RP stated he/she heard RV calling for help at approximately 6:30am on January 26, 2014, and found RV on the floor beside the bed. RP acknowledged that RV had urine and feces on himself/herself but was not aware that the feces were dry. RP believed that RV tried to get up to use the restroom without using the call system put in place and as a result RV fell. RP1 acknowledged RV did have numerous falls while at the AFH that included multiple falls from the bed. + + + + + +Witness #3 (W3), Witness #4 (W4) and Witness #7 were aware that RV had a history of falls while living at RP's AFH, including numerous falls out of the bed. W4 stated RP was provided a hospital bed for RV to help mitigate falls, however RV continued to experience falls. RP suggested to W4 that RP could move a table beside RV's bed to prevent falls. W4 advised RP use an alarm to alert RP if RV got out of the bed. Instead, RP placed an alarm on RV's door to alert RP if RV went to the kitchen during the night. + + + +RP stated RV would usually call out for help after a fall and RP would assist RV. During an incident on January 16, 2014, RP discovered RV on the floor and RV was non-responsive and was not capable of calling out for help. RP stated that in order to prevent falls RP installed a doorbell like system on RV's bed so RV could alert RP if he/she needed assistance. Due to RV's cognitive deficits RV could not consistently remember to use button. RP acknowledged that RV continued to fall out of the bed after the hospital bed was delivered. RP stated that he/she used a dog bone pillow to help prevent RV from rolling but it was ineffective. RP said he/she gave RV a bedside device to use but RV could not remember to use it. RP stated he/she placed a non-skid kitchen mat with a chux pad on the floor next to RV's bed to reduce the harm from a possible fall. The licensee failed to adequately care plan related to falls. The licensee's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +ES133986,505762,AFH,7/31/2013,"On or about July 31, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate food and nutrition for Reported Victim (RV). Witness #1 (W1) stated that the quality of meals RP would provide were poor and unappetizing. On multiple occasions W1 observed RV come to the dining table and see there was not a nutritious meal and would go without eating. Witness #2 (W2) stated a lot of what RP provides is microwaveable dinners. RP provided notes that indicate on 12/8/2012 RV weighed 194 pounds, on 5/13/2013 RV weighed 188 pounds and on 8/3/2013 RV weighed 172 pounds. RV had lost approximately 22 pounds from 12/8/2012 to 8/3/2013. The licensee failed to provide appropriate food and nutrition to RV. The failure is considered neglect of care and constitutes abuse.",2,,,,Neglect +JG135321,505804,AFH,5/22/2012,"Resident #1 was prescribed a narcotic pain medication to be taken on an ""as needed"" basis. The medication was kept in a cabinet at licensee's adult foster home (AFH). On May 22, 2012, it was discovered that one unused 30 count card of Resident #1's narcotic pain medication was missing. The medication was not used to benefit Resident #1 which is considered financial exploitation and constitutes abuse. The theft or destruction of Resident #1's narcotic pain medication was apportioned to an unknown individual. The facility failed to provide a safe environment. Licensee's failure is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Financial abuse +HB150781,505887,AFH,4/1/2015,"On or about April 1, 2015, it was alleged that Reported Perpetrator (RP) failed to administer medication as ordered to Reported Victim (RV). On 3/13/2015 RV was prescibed a Medication #1 25mg, one tablet by mouth, two times daily. On 3/25/2015 Medication #1 was changed to one 25mg tablet at bedtime and 12.5mg tablet daily as needed (PRN). RV's medication administration record for 4/5/2015 did not list Medication #1 as required. Medication #1 was being administered one half tablet in the am and one half tablet in the pm. The licensee failed to administer medication as ordered and failed to have accurate and updated medication administration record. The failures are a violation of Oregon Administrative Rules.",2,,,, +CO15166,505887,AFH,8/18/2015,,2,250,,, +MV118258,505951,AFH,10/13/2011,"On or about October 13, 2011, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #1 (RV1) and Reported Victim #2 (RV2). It was determined that RP used derogatory and inappropriate language toward RV1 and RV2. The licensee failed to protect RV1 and RV2 from verbal abuse. The failure is a violation of resident rights and constitute abuse.",3,0,,,Verbal/Mental abuse +ES117728A,506302,AFH,8/7/2011,"On or about August 7, 2011, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), and Reported Victim #5 (RV5). It was determined that the licensee failed to provide a safe environment for RV1, RV2, RV3, RV4, and RV5. The failures are a violation of Oregon Administrative Rules.",2,0,,, +ES117728B,506302,AFH,8/7/2011,"On or about August 7, 2011, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide a safe medication administration system for Reported Victim #1 (RV1). It was determined that for the past six to seven years RP2 stopped administering RV1's anticonvulsant and antimanic medication without authorization from RV1's primary care physician. During that time RP2 continued to document that the two medications were being administered. The licensee failed to provide a safe medication administration system for RV1. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Financial abuse +CO12004,506302,AFH,9/9/2011,"The licensor contacted the Adult Foster Home (AFH) on September 9, 2011. The licensor discovered that caregiver #1 had not completed the criminal history process and was not cleared to work in the AFH. Caregiver #1 was not a qualified caregiver and was left alone with residents on September 9, 2011. The licensee_x001A_s failure to ensure that a qualified caregiver was present and available in the foster home twenty-four hours per day on September 15, 2011 is a violation of the Oregon Administrative Rules (OARs).",3,250,,, +ES148398C,506302,AFH,9/4/2014,"On or about September 4, 2014, a complaint was received which alleged that at night Resident #1 (RV1) was restricted to his/her bedroom and the dining room. RV1's bedroom was located off the dining room. There were locks on the outside entrance to the dining room. During the course of the investigation, Witness #1 (W1), Witness #2 (W2), Resident #3 (RV3) and Resident #4 (RV4) reported that the dining room doors were locked at night which limited RV1 to his/her bedroom and dining room. Reported Perpetrator #3 (RP3) acknowledged that he/she locked the dining room from the outside as RV1 had a history of wandering. W1 stated that he/she had a conversation with RP3 approximately one year ago during which W1 specifically advised RP3 that residents may not be locked in a room. RP3_x001A_s actions are a violation of resident rights, are considered involuntary seclusion and constitute abuse. Responsibility for abuse was apportioned to RP3. + + + +Licensee failed to provide a safe environment for RV1. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Involuntary Seclusion +CO11015,506349,AFH,12/21/2010,,1,250,,, +NB116618,506517,AFH,3/21/2011,"On or about March 21, 2011, RP2 gave RV a scheduled medication as a PRN (as needed). The Licensee failed to have a safe medication administration system placing the RV at risk for harm.",2,0,,, +NB150264,506517,AFH,2/17/2015,,3,1150,,,Financial abuse +RD133158,506542,AFH,5/2/2013,"On or about May 2, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication system for Reported Victim (RV). A medication count was conducted and it was discovered that 9.5 of RV's as needed (prn) narcotice pain tablets were missing. According to RV's Medication Administration Record (MAR), RV was last administered the narcotic pain medication on 3/13/2013. RV was prescribed over the counter pain medication and had not needed the narcotice pain medication since it was last administered on 3/13/2013. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +RB118403,506546,AFH,10/27/2011,"On or about November 7, 2011, it was reported that the Licensee failed to maintain and adequate medication administration system. On October 27, 2011 Licensee did a narcotic pill count for Resident #1 (RV1) and only 91 narcotic pills out of 100 were accounted for. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +RB105999A,506598,AFH,12/27/2010,"On or about December 21, 2010, Licensee failed to protect Resident 1 and 2 from theft of narcotic pain medications.",2,0,,,Financial abuse +RB105999B,506598,AFH,12/27/2010,"On or about December 16, 2010 through December 29, 2010, Licensee failed to have a safe medication administration system. Caregiver failed to complete medication administration records appropriately for Residents 1 and 2, failed to properly document administration of PRN medication for Resident 1 and the medication cabinet was not secured as keys were accessible to anyone in the adult foster home.",2,0,,, +RB116868A,506598,AFH,4/28/2011,"On or about April 28, 2011, Resident #1's care plan did not reflect his/her change in care needs.",2,0,,, +RB116868B,506598,AFH,4/28/2011,"Resident #1's medication administration record was not updated following his/her return from the hospital with a new order. As a result, the resident received one incorrect dose of pain medication on April 29, 2011.",2,0,,, +RS117553A,506598,AFH,7/12/2011,"On or about July 12, 2011 it was reported that the Licensee failed to maintain an adequate medication system. The Licensee would substitute medications and did not note in RV's file. Medication records were poorly kept; inconsistent; inaccurate.",2,0,,, +RB120350A,506598,AFH,6/18/2012,"It was reported that on or about June 18, 2012, Licensee failed to protect Resident #1 from missing medication. It was found that Resident #1 was missing one narcotic pain medication from his/her bubble pack. Licensee replaced the missing narcotic pain medication from a stock of excess medication he/she kept in his/her room. There is no explanation as to what happened to Resident #1's missing narcotic pain medication. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RB120350B,506598,AFH,6/18/2012,"It was reported that on or about June 18, 2012, Licensee failed to maintain an adequate medication system. Licensee had a filing cabinet in his/her room with extra medication in it that belong to resident of the Adult Foster Home (AFH). All of the extra medication were medication that should had been discontinued. Licensee failed to properly dispose of the medication as required. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RB120350C,506598,AFH,6/18/2012,"It was reported that on or about June 18, 2012, Licensee failed to follow physician's orders. Resident #1 (RV1) had physician orders to receive scheduled narcotic medication at 9:00 a.m., noon, 4:00 p.m. and 8:00 p.m. RV1 takes his/her afternoon narcotic medication anywhere from 4:00 p.m. to 5:00 p.m. if he/she asks for it. If RV1 doesn't ask for it then he/she gets it with dinner around 6:00 p.m. RV1's last dose of narcotic pain medication is given between 9:00 p.m. and 10:00p.m. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO14083,506662,AFH,4/22/2014,Licensee had unqualified caregiver working in the home alone.,3,250,,, +BH117569B,506847,AFH,7/8/2011,"On or about July 27, 2011, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #3 (RP3) failed to treat Reported Victim (RV) with respect and dignity. It was determined that RV was intimidated while living at RP1's and RV did not receive assistance at night. Licensee failed to assure resident rights.",2,0,,, +MS121085,506890,AFH,9/18/2012,"On or about September 18, 2012, it was alleged that Reported Perpetrator (RP) failed to administer ordered medication to Reported Victim (RV). RV had an ordered medication for an anti-depressant and an order for a lipid lowering medication. For the month of August 2012, and September 2012 the anti-depressant and lipid lowering medication were not listed on the Medication Administration Record. It was determined that for the month of August 2012, and September 2012, RV did not receive h/h anti-depressant and lipid lowering medication. The licensee failed to administer two ordered medications to RV. The failures are a violation of Oregon Administrative Rules.",2,0,,, +MS151174A,506890,AFH,5/5/2015,"RV1 was a resident of the adult foster home. RV1 had a history of falls and wandering according to witness interviews and facility documentation. On May 1, 2015 RV1 fell in the driveway of the adult foster home and suffered skin abbrasions on his/her arm. On April 7th, May 1st, May 2nd and May 5th, 2015 RV1 attempted to and/or left the facility without assistance. On May 5th, 2015 RV1 left the facility and wandered down the street. RV1 refused to return to the facility and RP2 walked away from RV1. RV1 fell hitting his/her head on the pavement. RP2 refused to help RV1 up for a period of time and stated to RV1, ""see what happens?"" Both RP2 and RP1 did not call for medical assistance after RV1 hit his/her head on the pavement. RV1's care plan failed to address wandering or falls and failed to list any interventions to prevent and/or respond to them. The facility's failures are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Neglect +MS151174B,506890,AFH,5/5/2015,"On or about May 5, 2015 RV1 left the facility and fell into the road hitting his/her head on the pavement. RP2 approached RV1 while he/she was lying on the ground and ""scolded"" RV1 for ""not listening."" RP2 stated when interviewed that he/she told RV1 while he/she was lying on the ground, ""See what happens?"" Interviews and facility documentation refer to RV1 as ""stubborn"" and ""hard headed."" The facility failed to provide a safe and home-like environment. The facility's failure is a violation of the Oregon Administrative Rules (OAR's).",2,,,, +HB129955B,506917,AFH,5/2/2012,"On or about May 2, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) from involuntary seclusion. RV1 is a fall risk and uses a walker for assistance. RV1 is frequently up at night and wanders around the facility using his/her walker. Reported Perpetrator #2 (RP2) removed RV1's walker from his/her bedroom and stored it in the garage so that RV would not be able to use it to walk around the facility during the night. RP2 and RP1 admitted to putting RV1 in his/her bedroom when they cannot keep an eye on RV1. RP1 and RP2 will have RV1 go back into his/her bedroom if RV1 comes out too early. It was determined that the licensee failed to protect RV1 from involuntary seclusion. The failures are a violation of resident rights, are considered involuntary seclusion, and constitutes abuse.",2,0,,,Involuntary Seclusion +HB129955C,506917,AFH,5/2/2012,"On or about May 15, 2012, at approximately 6:00am Resident #1 (RV1) was found at the home of the facility_x001A_s neighbor. RV1 appeared disoriented and injured. Law enforcement was contacted and RV1 was transported to the hospital for treatment. It was determined that RV sustained a fall after he/she exited the licensee_x001A_s adult foster home (AFH). As a result of the fall RV1 had a concussion, fractured jaw bone, broken ribs, cracked tailbone and some scrapes and cuts. RV1 had a history of exit seeking during the day and night. Prior to the incident on May 15, 2012, an alarm system had been put in place and RV1 had exited the facility during the night without RP being aware RV1 was gone. No other precautions were taken. The licensee failed to provide a safe environment for RV1. The licensee_x001A_s failure is violation of Oregon Administrative Rule and constitutes abuse.",4,750,,,Neglect +MM106004,507085,AFH,12/14/2010,"It was reported that on or about December 14, 2010, Licensee failed to provide a safe environment for Resident #1 (RV1). Local law enforcement was contacted approximately six times in regards to non-residents being at the Adult Foster Home (AFH). Licensee employed 4 individuals prior to their criminal history check being completed and approved. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MM153578,507176,AFH,11/13/2015,"On or about November 13, 2015, the Department received a complaint which alleged Licensee had failed to maintain a safe medication administration system. During the course of the investigation, Licensee (RP) acknowledged that she had given Resident #1 (RV) one of his/her prescribed medications in the morning, instead of the evening. The Medication Administration Record (MAR) for RV was reviewed by the Adult Protective Services Specialist (APSS). The MAR did not reflect that the medication was given at other than the prescribed time of day. Additionally, it was discovered that medication had been left in RV's room unattended if RV was not awake at ordered time of day of administration. Licensee failed to provide a safe medication administration system. Licensee's failure is a violation of Oregon Administrative Rule.",2,,,, +MS132119,507341,AFH,1/14/2013,"It was reported that on or about January 14, 2013, Licensee failed to provide Resident #1 with adequate care. Resident #1 had to move to a new facility as Licensee couldn't meet his/her care needs. When Resident #1 arrived at the new facility his/her hair was greasy, there was dirt on his/her face and between his/her toes. Resident #1's forehead and scalp was scaly and there was dried mucus on his/her neck and face. Additionally, Resident #1 had body odor and his/her clothing was filthy. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BH120737A,507351,AFH,7/31/2012,"On or about August 6, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV was hospitalized from 8/1/12 to 8/5/12. RV was found to have extensive bruising on RV's left forehead, left chest, and thorax. Hospital notes indicate that the thorax bruising could relate to handling while being transferred into the ambulance. On August 10, 2012, RV made a visit to h/h physician and the notes from the visit dated 8/10/12 state that bruises on left chest and temporal region, in addition to fresh bruising on the central sternum and on the left flank were in different stages of healing. The licensee failed to provide a safe environment for RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +BH120737B,507351,AFH,7/31/2012,"On or about August 6, 2012, it was alleged that Reported Perpetrator (RP) failed to provide proper nutrition for Reported Victim (RV). On or about 8/1/12 Witness #3 (W3) noticed that RV had not urinated during the evening. RP1 was notified and advised that 911 be contacted. RV was transported to the hospital. RV was found to be dehydrated, anemic and malnourished. The licensee failed to provide proper nutrition for RV. The failure is a violation of resident rights, considered neglect, and constitutes abuse.",2,0,,,Neglect +CO13079,507433,AFH,6/6/2013,"On June 6, 2013, the licensor conducted a renewal inspection at the licensee_x001A_s adult foster home (AFH). During the inspection the licensor found that the smoke detector in Resident #4_x001A_s bedroom was removed. The licensee failed to install all required smoke detectors. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +SV129396,507438,AFH,3/5/2011,"On or about March 5, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from derogatory and threatening verbal comments. It was determined through interviews that RP1 made inappropriate verbal comments toward RV1 and RV2. The licensee failed to protect RV1 and RV2 from inappropriate verbal comments. The failures are a violation of Oregon Administrative Rules.",2,0,,, +MV148878B,507438,AFH,10/10/2014,"On or around October 10, 2014, APS received a complaint that the facility failed to protect RV2 from threats of punishment and humiliation. During the course of the investigation, APS substantiated that RP yelled at RV2 for eating too quickly and choking. RP made inappropriate statements to RV2 when RV2 did not remember to eat slowly. RP took RV2's food three or four times and blended it in a blender for RV2 to drink. RP blended RV2's food as a way to force RV2 to change RV2's behavior. RP insisted that RV2 drink a blended hamburger, which RP knew tasted terrible blended, and RV2 did not like it. RP's actions are a violation of resident rights, and constitute verbal/mental abuse.",2,,,,Verbal/Mental abuse +CO15188,507438,AFH,9/3/2015,Unqualified Caregivers and unsafe Medication Administration practices.,3,500,,, +ES120061,507628,AFH,5/13/2012,"It was reported that on or about May 13, 2012, Licensee failed to provide a safe environment for Resident #1 (RV1). On May 13, 2012, RV1 wandered out of the facility while the caregiver on duty was in the back of the house caring for the other residents. The alarm that was used to alert the caregiver if RV1 opened the door was inoperable as it was in the off position. Licensee's are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RD118155,507721,AFH,9/14/2001,"On or about September 20, 2011, it was reported that the licensee had not administered Resident #1's regular bedtime dose of an anti-anxiety medication on September 7, 2011 and September 8, 2011, as ordered by his/her medical professional. The investigation concluded that the licensee had failed to follow physician orders. Wrongdoing on the part of the licensee was substantiated.",2,0,,, +CO14226,507721,AFH,10/31/2014,"Provider has not completed required documentation for activities (offer and participation in six hours of weekly activities geared towards resident's interests) for 3 years. Violations were issued 10/31/12, 10/28/13, and 5/13/14, along with 10/14.",1,100,,, +SV117984C,507836,AFH,9/5/2011,"On or about September 5, 2011, Reported Perpetrator #2 (RP2) left the medication storage cabinet unlocked and unattended. Resident #1 (RV1) took medication from the unlocked medication cabinet and ingested them. RP2 then contacted RV1_x001A_s primary care physician and RP2 was directed to monitor RV1 for twenty four hours. The licensee failed to properly secure and store medication which placed RV1 at risk of serious harm. The failure is violation of Oregon Administrative Rule.",3,400,,,Neglect +MV128860,507836,AFH,1/5/2012,"On or about April 15, 2011, an emergency room physician wrote an order allowing the use of a gait belt as needed (PRN) when Resident #1 (RV1) is in a chair. Oregon Administrative Rule does not allow for PRN orders when restraints are used in an adult foster home. During the course of the investigation the facility admitted that they have used a velcro posey belt when RV1 has been in his/her wheelchair. RV1's care plan does not address physical/chemical restraints or alternative interventions. Facility failed to use a physical restraint in compliance with Oregon Administrative Rules.",2,0,,, +AL152057,508104,AFH,10/23/2014,"On or about October 23, 2014, the Department received a complaint which alleged the facility had failed to maintain accurate medication records. Resident #1 (RV) was prescribed multiple medications, including a blood thinner, a beta blocker and a blood pressure medication. During the course of the investigation, the Adult Protective Services Specialist (APSS) discovered that RV often refused to take his/her medications. On other occasions, staff at Licensee's adult foster home failed to dispense one or more of RV's medications. Staff failed to properly document all instances of refused or missed medications. Facility's failure to maintain a safe medication administration system is a violation of Oregon Administrative Rule.",2,,,, +HB116901,508112,AFH,5/4/2011,"It was reported that on or about May 4, 2011, Licensee failed to provide appropriate care for Resident #1 (RV1). Witness #1 (W1) arrived at the facility on May 5, 2011, during W1's visit RV1 had a bowel movement. W1 alerted staff and requested they clean RV1, after approximately an hour W1 reminded staff again that RV1 had a bowel movement. Finally W1 insisted a third time and facility staff cleaned RV1. RV1 waited over two hours for facility staff to clean him/her after having a bowel movement. Licensee's failures are a violation of resident rights. Wrongdoing on the part of the Licensee has been substantiated.",2,0,,, +CO16010,508112,AFH,1/7/2016,"Licensee failed to assure that a cregiver was qualified to provide care. Midigated factor, Licensee did sumbit a background check request before caregiver's approval had expired, but in insufficient time for the request to be approved. CP sanction granted for 200.00 - 50.00 = 150.00",3,150,,, +ES128935,508189,AFH,1/13/2012,"It was reported that on or about January 13, 2012, Licensee failed to provide and adequate medication system. Licensee failed to ensure Resident #1 received his/her medication as ordered by his/her physician. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RD120491,508193,AFH,5/17/2012,"On or about May 17, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim #1 (RV1). Between 4/19/12 and 5/24/12 RV1 underwent three rounds of antibiotics to cure a urinary tract infection. On 5/18/12 RV1's physician requested a urine sample for RV1 from RP. The urine sample was not submitted to the lab until 5/24/12. RV1's physician faxed an order to the RP for a blood draw for RV1 on 5/18/12. The blood draw was not done, another order was faxed by RV1's physician on 5/22/12 to have RV1's blood drawn by 5/23/12. RV1's blood was not drawn, another order was faxed to have RV1's blood drawn on 5/30/12. RV's blood was drawn on 5/30/12 and submitted. An order was faxed to the RP on 5/30/12 doubling RV's dose of blood thinner, the RP did not see the fax until the following day. The blood thinner was not doubled until 5/31/12.",2,0,,, +CO12020,508222,AFH,6/1/2011,"The licensor conducted a monitoring visit at the licensee_x001A_s Adult Foster Home (AFH) on June 1, 2011. Upon arrival, the licensor discovered that the licensee or resident Manager was not on the property and there was not a qualified caregiver on duty. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +FL133619,508271,AFH,6/24/2013,"On or about June 26, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to follow Reported Victim's (RV) care plan. RV's care plan notes that RV cannot walk and needs assistance in transferring. RV is a known fall risk and requires assistance in most activities of daily living. Reported Perpetrator #2 (RP2) took RV to the restroom. RP2 walked off the job and left RV on the toilet unattended. RV attempted to transfer unassisted which resulted in RV falling. RP1 heard RV fall and called Witness #2 for assistance. RV did not sustain any injury from the fall. Facility failed to provide a safe environment. Licensee's failure is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Neglect +CO16019,508271,AFH,1/26/2016,"Applicant failed to submit true and accurate information on the Department_x001A_s Provider Enrollment Agreement form. The Department has determined that applicant does not possess the appropriate good judgment and good personal character, including truthfulness, determined necessary by the Department to provide 24-hour care for adults who are older or adults with physical disabilities.",3,0,,, +ES133775,508287,AFH,7/3/2013,"On or about July 3, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate staffing for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Repoted Victim #4 (RV4), and Reported Victim #5 (RV5). Witness #1 (W1) made an announced visit to the licensee's adult foster home (AFH). Upon arrival W1 knocked on the door and did not get a response. After waiting approximately one minute W1 entered the AFH. W1 observed an RV at the dining table slumped over. W1 called out and no caregiver responded. After waiting approximately five minutes W1 called a contact number for the AFH. Three caregivers came from outside of the AFH. RV's were left alone for an uknown amount of time. The licensee failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES146081,508287,AFH,2/12/2014,"On or about February 12, 2014, Witness #3 (W3) arrived at licensee_x001A_s (RP1) adult foster home (AFH) to conduct a visit with Resident #1 (RV1). RP1 reported that W3 began his/her conversation with RV1 by asking RV1 if he/she was happy at the AFH. RP1 expected W3 to speak with RV1 only about medical issues but the conversation wasn_x001A_t about RV1_x001A_s medical needs. RP1 wanted to be a part of the W3_x001A_s visit with RV1 but W3 _x001A_didn_x001A_t want me to sit in_x001A_. RP1 stated that she thought it was wrong of W3 not to include RP1 in W3_x001A_s interview with RV1. + + + +During the conversation between RV1 and W3 that occurred in RV1_x001A_s room, RV1 reported to W3 that Reported Perpetrator #2 (RP2) yelled at RV1 and had often told him/her that RV1 was faking his/her disability. RP1 entered RV1_x001A_s room and demanded to know what RV1 had said about RP2. RV1 told RP1 that RP2_x001A_s hollering made RV1 _x001A_feel bad_x001A_. RP1 directly yelled at RV1 to stop telling W3 he/she is being abused or RP1 will _x001A_kick you [RV1] out immediately_x001A_. W3 stated that RP1 also told RV1, _x001A_You have damaged my floors because you are so fat. You are hated by all the clients in the home. None of us want you here._x001A_ W3 advised RP1 that she should not be speaking to RV1 in that tone of voice and stating hurtful things. Additionally, W3 pointed out that RP1 cannot kick RV1 out for reporting an allegation of abuse. + + + +RP2 then entered RV1_x001A_s room and confronted RV1 and demanded to know what RV1 had accused him/her of doing. W3 reported that RP2_x001A_s tone of voice was _x001A_very angry and harsh_x001A_. RV1 started to give an example that RP2 often told RV1 that there was nothing wrong with RV1 and that he/she can take care of him/herself. RP2 just laughed. + + + +RP1 told W3 that his/her interview with RV1 was over and RP1 immediately escorted W3 from the AFH. W3 reported that he/she was reluctant to leave RV1 because RV1 was _x001A_shaking and visibly upset_x001A_. RV1 was afraid of what was going to happen to him/her after RP1 made W3 leave him/her alone with RP1 and RP2, RP2 _x001A_scares me_x001A_. + + + +RV1 and W1 reported that when RV1 began crying that day, he/she had called Witness #1 (W1). W1 also stated that RV1 had nightmares for days after this incident. + + + +During the course of the investigation, RP1 acknowledged that W3 had also indicated that he/she needed to visit with another resident but RP1 told W3 that he/she could not see the other resident (RV2). + +Licensee failed to provide a safe environment as evidenced by: inappropriate verbal interactions between RP1 and RV1 and RP2 and RV1; restriction of RV1 and RV2_x001A_s ability to communicate privately with an individual of their choosing; and retaliation against RV1 and W3 who was acting on RV1_x001A_s behalf when a complaint was made. Licensee_x001A_s failures are a violation of resident rights and constitute emotional abuse. + + + +Responsibility for abuse has been apportioned to RP1 and RP2.",3,450,Substantiated,Substantiated,Verbal/Mental abuse +PT121888A,508355,AFH,12/1/2012,"On or about December 1, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) and RV butt heads. RP2 has been witnessed yelling at RV. RP2 admitted that h/she has raised h/h voice toward RV. It was determined that the licensee failed to protect RV from loss of dignity. The failure is a violation of Oregon Administrative Rule.",2,0,,, +PT121888B,508355,AFH,12/1/2012,"On or about December 1, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care and services to Reported Victim (RV). RV's room had a strong odor of urine and feces. RV's commode was observed to be filled with urine and feces and not emptied at approximately 1:00pm. Reported Perpetrator #2 (RP2) is instructed to change the commode every morning. RP2 stated that it is possible h/she overlooked emptying the commode. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rule.",1,0,,, +CO11061,508371,AFH,4/29/2011,,2,250,,, +MM118708,508371,AFH,12/12/2011,"On or about December 12, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) from inappropriate sexual advances. It was determined that Reported Perpetrator #2 (RP2) made inappropriate sexual comments toward RV1. The licensee failed to protect RV1 from verbal abuse resulting in RV1 feeling afraid, anxious, and uncomfortable. The failure is a violation of resident rights, and constitutes abuse.",3,0,,,Verbal/Mental abuse +MM128897,508371,AFH,10/31/2011,"On or about October 31, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) from inappropriate sexual contact. It was reported that RP2 sexually abused RV1. It was determined through interviews and observations that RP2 had a sexual relationship with RV1. The licensee failed to protect RV1 from inappropriate sexual contact. The failure is a violation of resident rights and constitutes abuse.",4,0,,,Sexual abuse +CO13139,508381,AFH,10/30/2013,"Licensee failed to have a safe medication administration system, failed to orient residents to the home and failed to have qualified caregivers.",3,750,,, +MF134965,508381,AFH,11/6/2013,"It was reported that on or about November 6, 2013, Licensee failed to provide proper care to Resident #1 by failing to follow Resident #1's care plan. Licensee's failures are a violation of Oregon Administrative Rules is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +CO14043,508381,AFH,12/5/2013,Licensee repetitively fails to provide a safe medication administration system,3,0,,,Neglect +CO14086,508412,AFH,4/30/2014,"On April 29, 2014, the licensee submitted her annual criminal background check. The licensor discovered the licensee's criminal background check had expired on 11/19/2013.The licensee operated the adult foster home (AFH) for approximately five months without a cleared criminal background check. The licensor made a visit to the licensee's AFH on 4/30/2014. During that visit the licensee acknowledged that she had operated the AFH without a cleared criminal background check for several months. The licensee's plan of operation notes that the licensee provides care alone for several hours at least two times a week. The licensee's conduct constituted a failure to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,250,,, +CO14123,508412,AFH,6/4/2014,"A renewal visit was conducted at the licensee's adult foster home (AFH) on June 4, 2014. Upon arrival caregiver KM was present. During the visit it was discovered that KM did not have an approved criminal background check as a caregiver. KM did have an approved criminal background check as a resident manager. It was acknowledged that KM was not working in the position of a resident manager. The licensee's conduct constituted a failure to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,200,,, +CO15240,508412,AFH,12/1/2015,uqualifed caregiver and MARs not initialed.,3,450,,, +HB135420,508444,AFH,12/17/2013,"On or about December 18, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RP was aware that RV was a fall risk prior to RV being admitted to the adult foster home (AFH). On 10/5/2013 RV was found on the floor next to his/her bed at the AFH. RV was transported to the emergency room and was found to have a urinary tract infection and a broken hip. RV was discharged to a skilled nursing facility. RV had multiple falls while at the nursing facility. RP placed a tab alarm on RV after he/she returned to the AFH on 11/5/2013. On 11/9/2013 RV fell in his/her room and sustained a skin tear on his/her arm and face. RP placed a pad next to RV's bed after this incident. On 12/15/2013, RV fell in te living room area of the AFH. RV did not show signs of injury or pain. The following day RV was transported to the emergency room due to altered mental status. RV was found to have a urinary tract infection and a pelvic fracture. RV fell while at the hospital and sustained a bruise. RV was discharged back to the AFH on 12/21/2013. The licensee failed adequately care plan related to RV's falls.",2,,,,Neglect +CO11071,508464,AFH,5/26/2011,provider failed to have qualified caregivers who could meet the needs of the resident resulting in change in resident condition and hospitalization,4,0,,,Neglect +BA118644,508490,AFH,9/14/2010,"It was reported that on or about September 14, 2010, Licensee failed to Provide basic care to Resident #1 (RV1). Sometime between September 14, 2010 and September 21, 2010 RV1 fell while residing in Licensee's Adult Foster Home (AFH) and broke a bone. Resident #1 took another fall on or about October 4, 2010 resulting in another broke bone. On both occasions Licensee failed to notify RV1's family and physician on the day the falls took place and failed to seek timely medical treatment. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",3,0,,, +SV105777B,508599,AFH,11/22/2010,"The investigator responded to a concern at Reported Perpetrator #1's (RP1) adult foster home. Upon arrival at the home, the investigator determined that Resident #2 (RV2) was home alone. RP1 indicated that RV2 had gone on an outing with his/her family and been dropped off at the adult foster home before he/she could arrive back at the home.",2,0,,, +KF128891,508683,AFH,1/4/2012,"It was reported that on or about January 4, 2012, Licensee failed to provide appropriate care to Resident #1 (RV1). On January 2, 2012, Licensee admitted RV1 into his/her Adult Foster Home (AFH) without completing a proper assessment of RV1's care needs. RV1 was at the AFH for less than 32 hours and Licensee called RV1's family to inform them he/she would not be able to meet RV1's care needs as RV1 was up all night and wouldn't sleep. Licensee's failures are a violation od Oregon Administrative Rules (OARs) Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +KF121758,508685,AFH,12/3/2012,"On or about December 3, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) and RV were having a verbal argument when RP2 yelled ""shut the fuck up! Just shut the fuck up!"" to RV. The licensee failed to protect RV from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HB116203,508750,AFH,1/25/2011,"On or about January 25, 2011, it was discovered Licensee failed to provide appropriate foot care to Residents 1, 2, and 3. Resident 1 had a medical condition require specific foot care regimen. This failure resulted in discomfort and harm to the residents.",2,600,,,Neglect +CO16107,508750,AFH,4/14/2016,SUSPENSION OF THIS HOME BASED IN PART ON ALLEGATION(S) OF ABUSE AT LICENSEE'S BARLOW ROAD HOME. CONDITIONS WERE PLACED ON BOTH HOMES IN ORDER TO ALLOW DEPT. STAFF TO IDENTIFY NEW PLACEMENTS FOR ALL RESIDENTS BEFORE SUSPENSION(S) WERE SERVED.,4,,,,Neglect +CO16028,508848,AFH,2/9/2016,"Licensee failed to have qualified caregivers. Her CPR/First Aid card expired on March 5, 2015 and the licensee admitted working alone in the AFH between March 15, 2015 and February 8, 2016. The licensee also failed to maintain functional smoke alarms in two bedrooms. Request for CP sanction granted and aggravated by $50.00 for the extended period of time the CPR/First Aid card had been expired.",3,800,,, +NB129662,508920,AFH,3/30/2012,"On or about March 30, 2012, it was reported that the Licensee failed to protect Reported Victim #1 (RV1) from financial exploitation. Reported Perpetrator #2 (RP2) admitted to taking 7 of RV1_x001A_s narcotic prescription pills while at the facility. RP2 admitted to ingesting 4 of those narcotic prescription pills and pocketing the remaining 3 without RV1_x001A_s knowledge.",3,0,,,Financial abuse +CO15059,508949,AFH,3/18/2015,"On March 16, 2015, the licensor conducted an unannounced visit at the licensee_x001A_s adult foster home. Upon arrival ND answered the door and was the only individual on duty. ND is a family member of the resident manager (RI) and is not a qualified caregiver. ND does not have an approved criminal background check as a caregiver. The licensee failed to have a qualified caregiver on duty as required.",3,250,,, +MS105587,508998,AFH,10/27/2010,"On or about November 1, 2010, it was reported that the Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee not follow education and training provided by Witness #6 (W6) concerning RV1. It Was found that wrongdoing on the part of the licensee was substantiated.",2,0,,, +CO13015,508998,AFH,1/31/2013,"It was reported that on or about January 31, 2013, Licensee failed to protect Resident #1 from financial exploitation. Licensee used Resident #1's debit card to make 4 unauthorized withdrawals from a Bank of America ATM and 8 unauthorized withdrawals from an ATM inside local Purple Parrot gambling establishments. Licensee's failures are a violation of Oregon Administrative Rule and constitute financial abuse. Wrongdoing on the part of the Licensee was substantiated.",3,0,,,Financial abuse +MF132282,508998,AFH,9/10/2012,"It was reported that on or about September 10, 2012, Licensee failed to protect Resident #1 from misappropriation of Funds. Licensee used Resident #1's debit card at a local gambling establishment unauthorized, and made unauthorized ATM withdraws with Resident #1's debit card. Licensee's failures are a violation or Oregon Administrative Rules, are considered financial exploitation and constitute abuse.",3,0,,,Financial abuse +ES116145,508999,AFH,1/14/2010,"On or about January 14, 2011, Licensee failed to contact 911 during an emergency and instead transported Resident 1 to the hospital personally. Resident 1's suffered moderate to severe harm as his/her condition continued to decline prior to receiving emergency treatment at the hospital.",3,0,,,Neglect +ES146217,508999,AFH,2/27/2014,"Resident #1 (RV) was prescribed Medication #3. An order of 30 tablets was filled by the pharmacy on February 18, 2014. RV_x001A_s Medication Administration Record (MAR) for February 2014 was reviewed. RV was dispensed Medication #3 on February 19, 2014, February 22, 2014 and February 27. 2014. RV_x001A_s February 2014 MAR did not indicate whether 1/2 tablet or 1 tablet was given to RV on each date. A medication count was conducted on February 28, 2014. The total number of tablets that remained of RV_x001A_s Medication #3 was 21, which left 6 tablets unaccounted for. + + + +Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) volunteered to take drug tests. RP1 and RP2 were advised that Medication #3 remains detectable in the system for only seven days. RP1 submitted her sample for testing that same day, February 28, 2014. RP1_x001A_s test result for the presence of Medication #3 was negative. RP2 initially told RP1 that he/she would provide a sample for testing on March 3, 2014. RP2 failed to follow-through with being tested on March 3, 2014. RP2 next reported to RP1 that he/she would comply on either March 6 or March 7, 2014. RP2 delayed the lab test until March 12, 2014. + + + +Loss of RV_x001A_s medication is considered financial exploitation and constitutes abuse. Responsibility for the abuse has been apportioned to RP2.",3,,Not Substantiated,Substantiated,Financial abuse +ES149010,508999,AFH,10/7/2014,"On or about October 22, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim (RV). Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) set up and administer RV's medication. RP2 acknowledged that he/she did not initial RV's medication administration record (MAR) on 10/23/2014 as required by Oregon Administrative Rule. RP3 stated that he/she forgets to write things down and he/she doesn't always document everything. RP3 stated that he/she had decided not to administer an ordered medication for RV because RV doesn't need another chemical in his/her system. + + + +Registered Nurse instructions dated 8/4/2014 instructed RP's to hold all condition medications until further notice. Physician notes dated 8/14/2014 notes that RP's started to administer condition medications to RV again. There was no order from the doctor directing them to do so. RV's doctor confirmed to continue to hold all condition medications. + + + +August 2014 MAR: + +Fifteen entries of administering one discontinued medication from 8/5/2014 through 8/22/2014. + +Two entries of administering a second discontinued medication from 8/5/2014 through 8/22/2014. + +Eight entries of administering a third discontinued medication from 8/5/2014 through 8/22/2014 + + + +September 2014 MAR: + +Twenty-four entries of administering a discontinued medication from 9/4/2014 through 9/27/2014 + + + +RV's clinical care summary dated 10/23/2014 notes that RV is to start a new medication. RV's October 2014 MAR does not list the new medication as required. The licensee failed to provide a safe medication administration system.",3,200,,, +ES149616B,508999,AFH,12/6/2014,"On or about December 17, 2014, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. On 12/6/2014 RP was observed yelling at RV to ""stop pushing my buttons."" RV's sibling is deceased. RV becomes upset when on the date of RV's sibling death. RP was observed telling RV that ""you should be over it by now."" The licensee failed to protect RV from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES150029,509063,AFH,1/23/2015,"On or about January 23, 2015, APS received a complaint that the facility failed to protect a resident (RV1) from a chemical restraint. During the course of the investigation, APS substantiated that Licensee directed a caregiver to administer a medication to the resident which had not been prescribed by a doctor to that resident. The resident had behaviors such as getting up at night and walking around the house. The non-prescribed medication would cause the resident to go to sleep. The APS investigator located the non-prescribed medication, which was found in a separate unmarked ""house/community"" medication bin. The medication found had an expiration date of November 29, 2012. The facility failed to protect RV1 from chemical restraint. The Licensee wrongfully used a chemical restraint on the resident; this constitutes abuse.",3,600,Not Substantiated,Substantiated,Restraints +ES133957A,509071,AFH,7/29/2013,"On or about July 30, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) resident rights. RV1's care plan states that ""caregivers are to assist RV1 with dressing and undressing tasks."" RP will have RV1 ask another resident to assist RV1 with dressing him/herself. RV1 feels embarrassed when he/she has to ask another resident for assistance with dressing. RP acknowledges asking another resident to help RV1 with dressing. The licensee failed to RV1's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES133957C,509071,AFH,7/29/2013,"On or about July 30, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to assure Reported Victim #1 (RV1) and Reported Victim #2 (RV2) resident rights. RP1 does not allow access to the kitchen. RP1 stated ""the kitchen is mine."" RP1 does not allow residents to use the kitchen sink or refrigerator. The licensee failed to protect RV1 and RV2's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +GP150557A,509250,AFH,2/19/2015,It was alleged that the facility failed to provide a safe medication administration system. It was determined that RV1's blood pressure medication was divided and RV1 received a half dose of his/her medication. Licensee's failure is a violation of the Oregon Administrative Rules.,2,,,, +AL116608,509283,AFH,12/14/2010,"During the month of December 2010, it was discovered that RV1 and RV2 were missing medications. The Facility failed to provide a safe medication administration system so that medications could be accurately reconciled.",2,0,,, +CO15102,509283,AFH,5/27/2015,Battery removed from smoke alarm in caregiver's bedroom.,3,250,,, +HB105760B,509355,AFH,12/2/2010,Resident #1 liked cats and preferred to sleep with the home's kittens. The kittens scratched the resident's legs several times. When Reported Perpetrator #1 saw the scratches she stopped letting the cats sleep with the resident. Resident #1 did not have any infection or other negative outcome.,2,0,,, +RD129778,509358,AFH,3/5/2012,"On or about March 5, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from theft of medication. It was determined through interviews and observations that RV left his/her key in his/her medication lockbox on March 5, 2012. RV discovered two bubble packs of a Narcotic pain medication missing. All of the bedrooms in the adult foster home were searched. The medication was not found. The licensee failed to protect RV from theft of medication. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Financial abuse +CO13148,509358,AFH,12/16/2013,"On December 16, 2013, the licensor conducted a monitoring visit at the licensee_x001A_s adult foster home (AFH). Upon arrival the licensee was not present. The licensee arrived shortly after. It was discovered that residents were left alone with an unqualified caregiver (Oscar) who had not completed the required criminal background check and caregiver work book and orientation. The licensee stated that she just ran to the store for five minutes. The licensee failed to have a qualified caregiver on duty as required. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +CO14014,509358,AFH,1/17/2014,"The Licensee has demonstrated substantial non-compliance with the rules and regulations that are applicable to the health and safety of caring for residents of an adult foster home. The Licensee_x001A_s failures have resulted in potential for serious harm to residents. These failures demonstrate the Licensee failed to exercise reasonable precautions to protect residents from any threat of harm to their health, safety or well-being. Settlement agreement entered in May, 2014. Withdrawal of Revocation and Condition. Sent 12/23/2014.",3,0,,, +CO14013,509358,AFH,1/17/2014,"Settlement agreement entered in May, 2014. Withdrawal of Revocation and Condition. Sent 12/23/2014.",3,0,,, +RD151838,509358,AFH,6/28/2015,"On or about June 29, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to provide a safe environment for RV. During the course of the investigation, APS substantiated the following: on or about the morning of June 28, 2015, RP gave RV another resident's medication (two over the counter pain/sleep pills) which caused RV to sleep for most of the next 24 hours. RP realized his/her error immediately and ensured that the other resident did not miss any medication doses. RP did not document the medication error in RV's progress notes, incident report, or medication administration records. RP's failure to provide a safe environment is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +BO153602,509358,AFH,7/17/2015,"On or about July 17, 2015, APS received a complaint that Licensee failed to administer medication to RV as directed by a physician. During the course of the investigation, APS substantiated the following: RV has a physician's order to take one tablet (.5 mg) twice a day (morning and evening) every day. Licensee stopped administering RV's medication every day because Licensee felt it made RV too groggy/sleepy and did not consult with RV's physician prior to stopping the medication. Licensee gives the medication ""as needed"". RV's blood test at his/her medical appointment on June 29, 2015, revealed that the medication was not in his/her system. The Medication Administration Record for July 2015 indicates that the documentation is given twice daily, then crossed out and written ""too strong"". Licensee's failure to administer medication to RV as directed by physician is a violation of resident rights, is considered neglect, and constitutes abuse.",2,300,Substantiated,Substantiated,Neglect +RD120090,509366,AFH,4/20/2012,"It was reported that on or about April 20, 2012, Licensee failed to protect Resident #1 from financial exploitation. Local law enforcement was contacted and Reported Peretrator #2 was cited for possesion of a controlled substance and theft in the third degree. Wrongdoing on the part of the Licensee was substantiated.",2,0,Not Substantiated,Substantiated,Financial abuse +RD120929,509366,AFH,8/15/2012,"On August 15, 2012, at approximately 11:30 AM it was discovered that nine of Resident #1's medication #1 pills were missing and not documented as being administered. Licensee was unable to determine what had happened to Resident #1's medications. Licensee's failed to Resident #1 from misappropriation of his/her medication. Licensee's failures are a violation of Oregon Administrative Rules, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +DL145614,509525,AFH,1/7/2014,"Resident #1 (RV1) was prescribed 5mg tablets of a narcotic pain medication to be given as needed for pain management. The order was for 1-2 tablets to be dispensed up to four times per day, not to exceed 8 tablets per day. A review of RV1_x001A_s medication records for December 2014 recorded that RV1 had been administered 10-5mg tablets within a 24 hour period on three occasions: December 9, 10 and 11, 2014. + + + +On December 23, 2013, an order was issued for Resident #2 (RV2) to be given 6 units of insulin every night at 8pm. RV2_x001A_s Medication Administration Records for December 2013 and January 2014 were reviewed. The December 2013 records indicated that RV2 was administered insulin on December 24, 2013, December 28, 2013 and December 30, 2013. RV2_x001A_s January 2014 medication records documented that RV2 was administered insulin every day between January 1 and January 7, 2014. Facility staff that administered insulin to RV2 had not been trained and delegated by an RN to perform that task. Caregivers at Licensee_x001A_s adult foster home were not delegated to give injections or test blood sugar levels for RV2 until January 7, 2014. + + + +Licensee failed to maintain a safe medication administration system. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,200,,, +CO15238,509525,AFH,11/20/2015,"failure to have a qualified primary caregivers, failure to maintain qualifications and requirements of a Licensee, caregivers sleeping in area designated as living area",3,1050,,, +BH150672,509536,AFH,2/10/2015,"On or about March 19, 2015, Adult Protective Services (APS) received a complaint that the facility failed to have a safe medication administration system. During the course of the investigation, APS determined that RV was prescribed an anticoagulant which varied according to blood levels. The medication was dispensed in 1 mg tablets, but RV's medical provider thought it was dispensed in 2 mg tablets. On 2/10/15, the medical provider sent an order for RV to receive 1 mg per day, and have 1/2 tablet per day. The order was not clear that 1/2 tablet should equal 1mg. RP1 did not realize the order was unclear and gave 1/2 tablet, at 0.5mg. RV was hospitalized with a stroke on 3/8/15 and died 3/10/15. Assessment shows the stroke was likely due to sub-therapeutic INR. APS found the incident occurred but wrongdoing was not substantiated.",0,750,Substantiated,Substantiated, +CO11038,509577,AFH,4/4/2011,,2,250,,, +ES116542,509580,AFH,3/13/2011,"Reported Perpetrator #2 (RP2) worked in Reported Perpetrator #1's (RP1) adult foster home in December 2010 and January 2011. Resident #1 (RV1) had a prescription for PRN (as needed) pain medications. The pharmacy delivered pain medications for RV1 to the facility on December 27, 2010 and January 4, 2011. RP2 signed the record receipt as having received the medication deliveries. RP1 and the investigator attempted to contact RP2 for more information but RP2 failed to cooperate in explaining the missing medications. The facility contacted law enforcement to report the theft of medications.",2,0,Not Substantiated,Substantiated,Financial abuse +ES152470,509580,AFH,8/13/2015,"It was reported that on or about August 13, 2015, Licensee failed to conduct a proper screening and assessment for Resident #1 (RV1) prior to admitting RV1 into his AFH. Licensee did not conduct a full assessment of RV1 prior to admitting RV1 into his AFH. RV1 had night needs and behaviors Licensee was not able to manage while RV1 resided at his/her AFH. RV1 went without an ordered medication from 7/27/15 through 7/31/15, because the medications were not available at Licensee's AFH when RV1 was admitted. Licensee was not able to meet the care needs of RV1 and Licensee sent RV1 to the hospital as a result of not being able to meet RV1's care needs. Licensee's failures are a violation of OARs and is a violation of Resident rights. Licensee's failure to ensure RV1 received his/her ordered medications is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee is substantiated.",2,,Substantiated,Substantiated,Neglect +ES133940,509601,AFH,7/26/2013,"Reported Perpetrator #1 (RP1) placed a sign in the bathroom of licensee_x001A_s adult foster home (AFH). The sign referred to Resident #1 (RV) by name and reminded RV to not _x001A_leave bathroom without checking clothes, and flushing toilet, putting away any messes and picking up wipes._x001A_ RV reported that the sign is _x001A_demeaning and shares my business with everyone._x001A_ During the course of the investigation, Witness #4 stated that _x001A_RP told me that s/he is well aware that h/h actions are violations of client rights._x001A_ The facility failed to treat Resident #1 with dignity and respect. The failure is a violation of resident rights and constitutes emotional abuse.",2,,,,Verbal/Mental abuse +CO14104,509644,AFH,3/7/2014,Filed to conduct timely fire drills as required.,2,200,,, +MV148444,509644,AFH,8/19/2014,"It was reported that on or about August 19, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee's dog defecated on the floor outside RV1's room and did not clean it up in a timely manner, resulting in RV1 stepping in dog feces. Licensee's failures is a violation od Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",1,,,, +HB135386,509656,AFH,12/13/2013,"Resident #1 had a credit card issued by a consumer electronics retailer. Reported Perpetrator #2 (RP2) is a caregiver at licensee_x001A_s adult foster home (AFH). RP2 asked Resident #1 if he/she could use Resident #1_x001A_s charge card to purchase items for his/her personal use. Resident #1 gave his/her permission to RP2. RP2 acknowledged that he/she began using RV_x001A_s credit account in approximately November/December of 2010. Documents obtained by the Department indicate that RP2 charged approximately $1,300.00 to Resident #1_x001A_s account for the time period between May 2011 and December 2011. RP2_x001A_s purchases included but were not limited to an Xbox, a computer and other items for his/her personal use. + + + +In November 2013, licensee wanted to purchase a computer but she only had $300.00 available. The cost of the computer she wanted was approximately $600.00. Licensee was aware that RP2 had been using Resident #1_x001A_s credit card. Licensee asked RP2 if he/she would ask Resident #1 if licensee could use his/her card too. Resident #1 gave his/her permission to licensee. On or about November 3, 2013, licensee purchased a computer for approximately $630.00 using Resident #1_x001A_s credit card. Licensee acknowledged that she knew that she shouldn_x001A_t be using Resident #1_x001A_s credit account for her personal use. + + + +On December 26, 2013, RP2 wrote a check made payable to the electronics retailer in the amount of $1,906.55. RP2_x001A_s check paid Resident #1_x001A_s credit account balance in full. + + + +The licensee failed to provide a safe environment. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,400,Substantiated,Substantiated,Financial abuse +KF149746,509701,AFH,12/31/2014,"On or about December 31, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). On 11/7/2014 RV was taken to a clinic for blisters on his/her butt which was being treated by RP with desitin. RP was directed to refer home health services for RV. Home health was not referred to by RP or witness #1 (W1). RV became more incontinent due to an increase of fluid retention medication. RV expressed pain and discomfort due to the blisters. RP stated that during a trip to Bend, OR from Christmas Valley, OR to see RV's physician on 12/23/2014, RP noticed sores on RV's buttocks. Witness #5 (W5) reviewed the colored photos of RV's sores and determined that they were urine burns. W5 stated that the burns could not have developed during a car ride from Christmas Valley, OR to Bend, OR. The licensee failed to provide appropriate care and services to RV. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +RB117046B,509708,AFH,5/19/2011,"W2 had not initialed RV1 and RV2 MARS for the 8:00AM medication pass on May 24, 2011 at 11:00 AM when MARS was reviewed by investigator. W2 attempted to initial the MARS prior to allowing the investigator to observe them. Upon review of the MARS in question on June 2, 2011, the medications were signed as if given on time, no late entry noted. W2 had personal item with 3 bottles of medication inside unsecured in area accessible to residents.",2,0,,, +CO14112,509708,AFH,6/13/2014,"The licensor received a complaint that there was not a qualified caregiver on duty at the licensee's adult foster home (AFH) on June 13, 2014. The licensor contacted the licensee on June 16, 2014. The licensee acknowledged that caregiver #1 (C1) provided care alone to residents without a cleared criminal background check on June 13, 2014, for approximately twelve hours. The licensee stated that she had not been keeping track of when her caregivers background checks expired. The licensee's conduct constituted a failure to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,250,,, +CO16006,509758,AFH,1/5/2016,Failure to have approved criminal background clearance,3,200,,, +CO15120,509771,AFH,6/19/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +CO15122,509771,AFH,6/22/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +HB134032,509791,AFH,8/6/2013,"It was reported that on or about August 6, 2013, Licensee failed to provide Resident #1 (RV1) adequate care and services. Licensee gave RV1 the incorrect medications. Licensee did contact a registered nurse who told Licensee to contact RV1's primary care physician but it was after hours so he/she then told Licensee to send RV1 to the hospital. Licensee did not call 911 until 8 and a half hours later. Licensee failures are a violation of Oregon Administrative Rules, is considered neglect and constitutes abuse.",3,400,,,Neglect +CO14191,509888,AFH,9/16/2014,FOP sent 12/8/14,2,250,,, +DA118023,509934,AFH,9/15/2011,"On or about September 15, 2011, it was alleged that Reported Perpetrator #2 (RP2) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4) from verbal abuse. It was determined that RP2 makes inappropriate verbal comments to RV1, and RV2. Failure of licensee to protect RV1, and RV2 from inappropriate verbal comments was substantiated.",2,0,,, +DA116856,509934,AFH,4/26/2011,"It was reported that on or about April 26, 2011, Licensee failed to provide a safe environment for Resident #1 (RV1). On April 26, 2011, RV1 managed to unlock the sliding glass door, open and almost close it. Descend the stairs and exit the yard of the Adult Foster Home through the gate. Licensee's failures are aviolation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB118082,50A028,RCF,9/24/2011,"Resident #1 was prescribed a pain patch to be changed every 72 hours four chronic pain. On 9/24/11 the Medication Administration Record (MAR) documentation indicates that it was changed. It was discovered that it had not been changed since 9/21/11, resulting in Resident #1 suffering more pain.",2,0,,,Neglect +HB118234,50A028,RCF,10/15/2011,"The facility failed to adequately care plan for Resident #1_x001A_s falls. Resident #1 fell and broke his/her hip. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB118495,50A028,RCF,11/16/2011,The Medication Administration Record was written incorrectly for Resident #1's narcotic medication dosage resulting in him/her receiving the incorrect dosage. There was no observed negative outcome to Resident #1 receiving the higher dosage.,2,0,,, +HB118546,50A028,RCF,11/28/2011,The facility failed to provide a safe medication administration system regarding Resident #1's medication administration and his/her daily visits to his/her spouse in another facility building. Resident #1 was administered a double dose of medication. There was no observable negative outcome to him/her.,2,0,,, +HB118615,50A028,RCF,12/5/2011,The facility failed to provide a safe medication administration system resulting in Resident #1 receiving an incorrect dosage of medication.,2,250,,, +HB128910,50A028,RCF,1/6/2012,Resident #1 was administered an incorrect dose of medication for approximately four days and Resident #2 was administered an incorrect medication on one day. There were errors on the Medication Administration Records and medication packs. Physicians were notified and neither resident had observable negative effects. The facility failed to maintain a safe and adequate medication administration record. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB118800,50A028,RCF,12/29/2011,Resident #1 did not receive his/her correct medication dosage on 12/28/11 and 12/29/11. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB129122,50A028,RCF,2/1/2012,Resident #1's care plan to use a gait belt was not followed on at least two occasions. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB129339,50A028,RCF,2/26/2012,The facility failed to administer Resident #1 his/her pain medication as ordered on 2/26/12 and there were no complaints of pain. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +HB121110,50A028,RCF,9/16/2012,Resident #1 had an un-witnessed fall in front of his/her wheelchair and discovered to have a fractured right ankle. He/she did not have a fall prevention plan because there was no prior history; however his/her care plan was updated after this fall to include wheelchair foot rests at all times.,0,0,,, +HB150098,50A028,RCF,2/2/2015,"Resident #1_x001A_s service plan instructed staff to use a sit-to-stand machine. On 1/30/2015 and 2/01/2015, Resident #1 experienced a fall when staff were not using the sit-to-stand machine. After the 1/30/2015 fall, he/she was not placed on alert charting nor documented communication provided to staff. Resident #1 went to the hospital after the 2/01/2015 fall and was diagnosed with a fracture. The facility failed to ensure Resident #1_x001A_s service plan was followed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB152331,50A028,RCF,8/3/2015,"On 8/3/15 at approximately 3:00am, Resident #1 was found outside on the ground of the courtyard. He/she sustained bruising on his/her face and knees and a fractured left hand. The facility failed to ensure the exit door alarm was properly functioning to alert staff when Resident #1 exited the door. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +SV117314,50A034,RCF,6/22/2011,"Resident #1 was care planned for falls and staff were to ensure the body pillow was tucked in place when he/she was in bed to prevent rolling out of bed. On 6/22/11, Reported Perpetrator 2 failed to tuck the body pillow in resulting in Resident #1 rolling out of his/her bed to the floor sustaining a fractured hip.",3,0,Not Substantiated,Substantiated,Neglect +SV117852,50A034,RCF,8/25/2011,Reported Perpetrator 2 failed to attach Resident #1's tab alarm when he/she sat and left Resident #1 in a chair. The door to the outside courtyard had been propped open gaining access to Resident #1. He/she was found on the ground with a cut to his/her forehead.,2,0,Substantiated,Substantiated,Neglect +SV117568B,50A034,RCF,7/11/2011,Resident #1's jewelry was reported missing in April 2011 and May 2011; however the facility failed to investigate or notify local law enforcement timely. The jewelry was not found.,2,0,,,Financial abuse +SV117568C,50A034,RCF,7/11/2011,The facility failed to obtain a physician's order before making changes to Resident #1's medication from PRN to routinely three times a day.,2,0,,, +CO13035,50A034,RCF,3/8/2013,"The facility failed to monitor and ensure a resident to resident altercation was thoroughly investigated, reviewed timely by the administrator and reported to local SPD or AAA office in order to rule out the possibility of abuse. Resident #13 experienced increased pain and anxiety. The facility failed to monitor Resident #11 who experienced a significant change of condition, related to skin breakdown. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +CO13076,50A034,RCF,5/29/2013,"The facility failed to evaluate and monitor Resident #16_x001A_s significant change of condition, and failed to ensure an RN assessment was completed for his/her significant change of condition. Resident #16 experienced a severe weight loss. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV129647,50A034,RCF,3/19/2012,"Resident #1 required daily catheter and peri-care and facility staff were provided with guidelines regarding how to provide that care. Resident #1 complained of pain, was taken to the urologist and diagnosed with a visible yeast infection in the peri-area. A copy of Resident #'1s Medication Administration Record (MAR) was provided by Witness 1 and stated there was no morning peri-care on 01/18/12 and no catheter care on 01/19/12. The facility provided a copy of the MAR at a later date which stated care was provided on 01/18/12 and 01/19/12. The facility failed to provide medical treatment as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +The Notification of Findings was completed at a later date; therefore a civil penalty was not issued due to the extended period of time between the incident date and processing by the Department.",3,0,,,Neglect +MV133378,50A034,RCF,5/24/2013,"Reported Perpetrator 2 (RP2) changed Resident #1's shirt in a public area of the facility in front of other residents, resulting in his/her loss of dignity. RP2 pulled Resident #2 by the wrist, the use of physical force. RP2 is found responsible for physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +MV133576,50A034,RCF,6/20/2013,The facility failed to care plan and provide nail care assistance to Resident #1. The facility's failure is a violation of Oregon Administrative Rules.,2,,,, +MV133840,50A034,RCF,7/16/2013,"The facility failed to provide appropriate care and monitor Resident #1 with his/her known behaviors, ultimately failing to provide a safe environment. Resident #1's behavior increased resulting in an altercation with Resident #2 on 7/14/13 and 7/16/13 resulting in pain and unreasonable comfort. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MV133645,50A034,RCF,5/11/2013,"The facility failed to provide appropriate care in a timely and appropriate manner, according to Resident #1's care plan, resulting in a fractured hip from a fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +MV133945,50A034,RCF,7/16/2013,"Resident #2 struck Resident #1 on the back multiple times resulting in bruising. Resident #2 had prior history of aggressive behaviors. The facility failed to provide a safe environment and failed to implement interventions regarding behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MV132175,50A034,RCF,11/4/2012,"Resident #1 and Resident #2 had an altercation resulting in a fall with injuries. Resident #1 and Resident #2 had prior aggressive behaviors; however the facility failed to provide a safe environment and failed to implement interventions regarding their behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MV135477,50A034,RCF,11/30/2013,"The facility failed to provide a safe environment by not implementing interventions and monitoring for Resident #1 who exhibited behaviors that resulted in an altercation between Resident #1 and Resident #2. Resident #1 punched Resident #2 in the chin. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +MV134130,50A034,RCF,7/31/2013,"Resident #1 had a known history of aggressive behaviors toward others. Resident #1 struck Resident #2 below the right eye and cut his/her cheek. It was discovered that Resident #1 had an infection. The facility was aware that he/she would become more agitated when he/she had an infection. The facility failed to provide a safe environment; implement effective interventions; and monitor Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MV148115,50A034,RCF,8/9/2014,"Resident #1 had a history of wandering. On 8/9/14, he/she left the facility and walked down the street. Resident #1 was returned by local law enforcement. The facility failed to implement safety measures regarding Resident #1's wandering behaviors to ensure a safe environment. The failures are a violation of Oregon Administrative Rules.",2,,,, +MV145733,50A034,RCF,1/1/2014,"Resident #1 had chest pain, was vomiting and pulled the call light; however Reported Perpetrator 2 (RP2) never responded to his/her room. Resident #1 was transported to the hospital for treatment. RP2 failed to provide assistance to Resident #1. RP2's actions are considered neglect of care and constitute abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +CO15081,50A034,RCF,3/25/2015,See license condition #RCFCP15-006.,3,,,,Neglect +MV159953,50A034,RCF,1/18/2015,"Resident #1 took Morphine two times daily for chronic pain. He/she was given a dose the morning of 1/17/15 and then went without through 1/19/15. Resident #1 went to the hospital twice during that time due to severe pain. The facility failed to provide a safe medication administration system to ensure Resident #1's pain medication was ordered and available to administer. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO15101,50A034,RCF,5/21/2015,"On April 9, 2015, a condition was placed on the facility_x001A_s license requiring a Restriction of Admissions (ROA) that restricted admissions for diabetic care residents and that the Department ROA poster must be posted on all facility entrances and exits. + + + +On or about May 15, 2015, a review of facility doors at Farmington Square _x001A_ Salem revealed that the ROA poster had been removed and altered. The facility failed to follow the requirement set out in Order Imposing License Condition #RCFCD15-006 (incorporated by reference).",2,200,,, +MV151022,50A034,RCF,4/18/2015,"Resident #1's purse was found in Resident #2's room in the closet, but the card with money in it was missing. Resident #2 had previous history of walking into Resident #1's room unwelcomed and would walk around the facility taking/removing items. It's unclear who took Resident #1's money. The facility failed to take reasonable precautions and care plan for Resident #2's behavior to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care resulting in financial exploitation and constitute abuse.",2,,Substantiated,Substantiated,Financial abuse +CO11044,50A070,RCF,3/8/2011,"The facility failed to evaluate, monitor, and ensure an RN assessment was completed for skin breakdown and short term change of condition; and failed to coordinate care services from home health. Resident #3 experienced worsening of a wound. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB116408,50A070,RCF,2/22/2011,"The facility failed to adequately assess and implement effective interventions, and care plan appropriately regarding Resident #1's behaviors resulting in several resident-to-resident altercations.",2,0,,,Neglect +HB118207,50A070,RCF,10/11/2011,Resident #1 has fragile skin and is care planned for staff to apply geri sleeves on every morning. RP2 did not place geri sleeves on Resident #1 as care planned resulting in skin injury. RP2 was found responsible for abuse.,2,0,Not Substantiated,Substantiated,Neglect +HB129164,50A070,RCF,2/5/2012,Resident #1 was care planned with behaviors and to have at least two feet of personal space from others. The facility failed to follow his/her care plan resulting in a non-injury resident altercation on 2/5/12 and 2/6/12. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB133201A,50A070,RCF,5/2/2013,"Resident #1 experienced an un-witnessed fall in his/her room resulting in injury. The facility failed to provide a safe environment and failed to follow his/her care plan. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB133201B,50A070,RCF,5/2/2013,"Resident #1 had missing furniture; however at some point the furniture went missing, reportedly perhaps during the facility remodel. A search was conducted, but the items were not located. The facility failed to provide a safe environment resulting in the loss of Resident #1's property. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +HB150025,50A070,RCF,1/23/2015,"Facility standard protocol is to have two staff members present for a resident group activity. One staff person was left to the activity and Resident #1 and Resident #2 got paint in and around their mouths. Poison control was called and was given instructions. There was no known negative outcome, however they were exposed to potential harm. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules.",2,,,, +HB153792,50A070,RCF,11/24/2015,"The facility failed to properly care plan for behaviors to ensure resident safety, resulting in resident altercations. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +HB153220,50A070,RCF,10/20/2015,"The facility failed to follow care plans were followed and failed to implement interventions for behaviors to ensure resident safety. Resident #1 and Resident #2 had an altercation causing injury. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES120649,50A074,RCF,7/25/2012,"Reported Perpetrator 2 (RP2) was assigned to provide care to Resident #1, Resident #2, Resident #3 and Resident #4 on his/her shift July 25, 2012 from 6am - 2pm. Residents #1 thru #4 were all found without having been provided the scheduled care and RP2 admitted to have not provided that care. RP2 failed to provide needed services, which is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +ES150771,50A074,RCF,3/30/2015,The investigation findings and video camera footage revealed that Reported Perpetrator 2 (RP2) stole narcotic medications belonging to Resident #1. RP2's actions are considered theft and constitute financial exploitation which is considered abuse. The facility failed to provide a safe medication administration system to prevent theft of medications and is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Financial abuse +ES152039,50A074,RCF,7/12/2015,"The facility and Reported Perpetrator #2 failed to adequately care plan for interventions to prevent Resident #2 sexual behavior. Resident #2 entered Resident #1's room and inappropriately touched him/her. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,Substantiated,Substantiated,Neglect +MS132591A,50A083,RCF,3/7/2013,"The facility failed to provide adequate care resulting in Resident #1 experiencing skin breakdown. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +MS132591B,50A083,RCF,3/7/2013,"The facility failed follow care plans for Resident #1 and Resident #2. Resident #1 fell and suffered a laceration to his/her head requiring 8 staples. Resident #2 fell and suffered a fractured hip. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,0,,,Neglect +MS133054,50A083,RCF,4/22/2013,Reported Perpetrator 2 (RP2) grabbed Resident #1's wrists causing him/her pain and bruising. The facility failed to provide a safe environment for Resident #1 and the failure is a violation of Oregon Administrative Rules. RP2 is found responsible for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +MF134986,50A083,RCF,10/1/2013,"The facility failed to intervene and assess when Resident #1 experienced a change of condition. He/she experienced weight loss and was admitted to the hospital for a severe infection and cellulitis. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS147186B,50A083,RCF,5/23/2014,The facility failed to ensure a safe medication administration system and to have an accurate medication administration record regarding Resident #1's medication order.,2,,,, +MS147186A,50A083,RCF,5/23/2014,"The facility failed to monitor and follow Resident #1_x001A_s care plan to conduct body and skin checks at shower times and to make notifications of any changes. He/she was discovered to have a swollen, infected arm and was admitted to the hospital. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS147041A,50A083,RCF,5/13/2014,"Resident #1's prescribed sleep aid was increased. He/she became more sedated and difficult to arouse due to the change and there was no documentation of side effects for a period of approximately two months. Resident #1 did become more alert and able to function after the sleep aid was discontinued. The facility failed to prove a safe medication regime. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS147041B,50A083,RCF,5/13/2014,"Resident #1's care plan stated to check for and report any changes in skin conditions when he/she was showered; however there were no reports of changes made for approximately three months. The facility failed to follow his/her care plan and failed to provide proper wound care. Resident #1's pressure wound worsened. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS146514A,50A083,RCF,3/27/2014,"Reported Perpetrator 2 (RP2) had a history of being disrespectful to residents and had been moved to another building due to complaints. RP2 yelled at Resident #1 and told him/her to ""shut up"" which is considered verbal/emotional abuse. The facility failed to protect Resident #1 from verbal/emotional abuse knowing RP2's history. The failure is a violation of resident rights, is considered neglect of care resulting in verbal/emotional abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +MS146514B,50A083,RCF,3/27/2014,"Reported Perpetrator 2 (RP2) had a history of being disrespectful to residents, being rough and aggressive to residents and was intimidating. RP2 grabbed Resident #1's neck which is considered physical abuse. The facility failed to protect Resident #1 from physical abuse knowing RP2's history. The failure is a violation of resident rights, is considered neglect of care resulting in physical abuse.",2,,Substantiated,Substantiated,Physical Abuse +MS148639,50A083,RCF,9/22/2014,"The facility failed to assess and intervene for approximately three days after Resident #1 fell and complained of pain. Resident #1 was diagnosed at the hospital having a wrist fracture requiring a cast. The facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS134702,50A083,RCF,10/8/2013,"Reported Perpetrator 2 (RP2) was an employee of the facility. RP2 took two of Resident #1's rings and pawned them. RP2 is found responsible for theft, which is considered abuse means of financial exploitation. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +MS149198,50A083,RCF,11/10/2014,"Resident #1 and Resident #2 were found unsupervised in Resident #2's room and both had injuries. Resident #1 had history of behaviors. The facility failed to implement interventions and ensure a safe environment for Resident #1 and Resident #2. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS148724,50A083,RCF,9/22/2014,"On 9/22/14, Resident #2 entered Resident #1's room and ""shoved"" Resident #1 causing him/her to fall and sustain injury. Resident #2 had known behavior risks. The facility failed to implement appropriate interventions for Resident #2 to ensure a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS149228,50A083,RCF,11/10/2014,"Resident #1 had prior altercations with other facility residents. Resident #1 punched Resident #2 in the side and punched Resident #3 in the nose causing it to bleed. The facility failed to implement effective interventions for Resident #1 to ensure a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS151483,50A083,RCF,6/3/2015,"Resident #1 had behaviors that included biting, scratching, pinching, yelling and throwing objects. He/she had 5 (five) incidents of physical aggression involving staff and residents between 4/4/15-6/8/15; however there were no interventions noted in his/her care plan regarding his/her behaviors until 6/4/15. On 6/3/15, Resident #1 had a physical altercation with Resident #2 resulting in a skin injury to Resident #2's face. The facility failed to appropriately care plan and implement interventions regarding Resident #1's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS152771,50A083,RCF,9/10/2015,"Resident #1 had a history of pressure ulcers and skin integrity were at risk. Resident #1_x001A_s care plan was updated for staff to reposition him/her every 2 hours for right hip wound; however there was no documentary evidence that repositioning occurred. His/her wound worsened and was transported to the hospital for treatment. The facility failed to follow his/her care plan to adequately provide care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,2500,,,Neglect +MS152935,50A083,RCF,9/25/2015,"On 9/25/15, Resident #1 and Resident #2 had an altercation resulting in injury. The facility failed to implement interventions and care plan for behaviors to ensure safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS153225,50A083,RCF,10/21/2015,"The facility failed to ensure Reported Perpetrator 2 treated Resident #1 with dignity and respect, which violates Oregon Administrative Rules.",2,,,, +HB116163,50A143,RCF,1/18/2011,DRAFT - Resident #1 was care planned with wandering behaviors and staff to provide redirection.,2,300,,, +HB120762,50A143,RCF,8/7/2012,Resident #1 threw water at Reported Perpetrator 2 (RP2) and RP2 in return yelled at Resident #1 and hit him/her in the face. Resident #1 was examined and found to have swelling and puffiness on his/her cheek. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +HB121147,50A143,RCF,9/24/2012,Reported Perpetrator 2 (RP2) roughly grabbed Resident #1's arm in an effort to maneuver him/her. Resident #1 told RP2 that it hurt. Resident #1's arm area was observed to be pinkish/reddened and he/she was crying. RP2 is found responsible for physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +HB134644,50A143,RCF,10/8/2013,"The facility failed to ensure a safe medication administration system and Resident #1 was given wrong doses of medication on two separate occasions. Resident #1 suffered significantly low blood sugar levels This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB148986,50A143,RCF,10/21/2014,"Resident #1 and Resident #2 were roommates and had a history of altercations. They were in their room, a verbal argument ensued and escalated and Resident #2 bit Resident #1 on the hand. The facility failed to provide a safe environment for Resident #1 and Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB150383,50A143,RCF,2/25/2015,"Resident #1 had a history of falls from transferring without assistance and was to have his/her tab alarm on at all times to alert staff when attempting to stand or transfer. On 2/14/15, he/she had a fall and the tab alarm sounded but couldn't be heard from the location of the building where staff were. It took approximately 15 minutes for staff to respond. Resident #1 appeared anxious and humiliated. The facility failed to ensure an effective tab alarm was in use to provide a safe environment. The failure violates Oregon Administrative Rules.",2,,,, +HB151728,50A143,RCF,6/25/2015,"Resident #1 fell and sustained injuries. He/she had had three non-injury falls prior to this injury fall. The facility failed to investigate, failed to adequately care plan, and failed to implement interventions to reduce falls and provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +HB152482,50A143,RCF,8/17/2015,"Resident #1 was care planned as a two person assistance required for transfer and to use a gait belt for all transfers. The investigation discovered that not all staff follow the care plan. Resident #1 was found with finger sized bruising on the under area of his/her arm. The facility failed to ensure Resident #1's care plan was followed to ensure his/her safety and free from harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES105176,50A149,RCF,8/30/2010,The care plans for Resident #1 and Resident #2 did not properly address the threat posed to Resident #1 by Resident #2.,2,0,,, +ES120123,50A149,RCF,5/20/2012,"The facility failed to protect residents from inappropriate sexual contact of actions by Resident #1. On 5/19/12, Resident #1 was care planned for one-to-one supervision after sexual behavior incidents with two residents. On 5/20/12, staff neglected to provide the one-to-one supervision and Resident #1 sexually contacted a third resident. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse and constitutes abuse.",3,2500,,,Sexual abuse +ES132950,50A149,RCF,4/14/2013,The facility failed to provide a safe medication administration system resulting in Resident #2 receiving his/her medication in the morning instead of at night. Resident #2 had no observable ill effects. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES153251,50A149,RCF,10/11/2015,"Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan resulting in bruising to Resident #1. RP2's actions are considered neglect of care, which constitutes abuse. The facility failed to update his/her care plan in a timely manner to ensure instructions were clear to staff. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +ES153901,50A149,RCF,12/10/2015,Resident #1 received injuries from Reported Perpetrator 2 (RP2) on both wrists and arms. RP2's actions are considered physical abuse. The facility failed to provide a safe environment which violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +ES164160,50A149,RCF,12/31/2015,The facility failed to ensure caregivers were awake to meet the 24 hour scheduled and unscheduled needs of Resident #1. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +ES116411,50A165,RCF,2/21/2011,"Resident #1's cash was placed in his/her room lockbox for safekeeping and the only known key returned to Witness #3. When he/she left the facility approximately a month and half later, the money was missing. It was discovered that many of the lockboxes were keyed alike including the one in Resident #1's room.",2,0,,,Financial abuse +ES117023,50A165,RCF,5/16/2011,Resident #1 and Resident #2 had an encounter a few weeks prior and Resident #2's care plan was altered to address his/her anxiety and exit seeking behaviors. Resident #1 was known to have a proprietary attitude towards the locked front door to the facility which resulted in a altercation when Resident #2 approached. Neither resident was emotionally or physically harmed.,2,0,,, +ES105455A,50A165,RCF,10/6/2010,The facility failed to take reasonable precautions to protect the safety of residents regarding the physical door between the ALF and the RCF. The door did not have a window allowing visual site. Resident #1 was found on the floor by the opening of the door and suffered a fractured hip. It was determined unclear if Resident #1 fell prior to or during the door being opened.,3,0,,,Neglect +ES117646,50A165,RCF,6/7/2011,Resident #2_x001A_s discontinued medications were included in Resident #1_x001A_s discharge medications to another facility. Neither resident missed any medications nor received the incorrect medications.,2,0,,, +ES121537,50A165,RCF,1/1/2012,"Facility staff could not find Resident #1 for approximately 5 hours. He/she was found sleeping on the floor in an empty room. He/she had no injuries or pain. The facility failed to provide a safe environment for Resident #1, exposing him/her to potential harm. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES146825,50A165,RCF,4/16/2014,"Resident #1 and Resident #2 had known prior resident to resident altercations. Resident #1 slapped Resident #2 twice in the face. The facility failed to implement effective interventions and monitor to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES146841,50A165,RCF,4/19/2014,"Resident #1 was locked inside a room against their will for 45 minutes. Reported Perpetrator 2 and 3 were found responsible for locking Resident #1 inside the room, which is involuntary seclusion and constitutes abuse. The facility failed to protect Resident #1 from involuntary seclusion and this is a a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Involuntary Seclusion +BH117534,50A214,RCF,7/14/2011,The facility failed to administer Resident #1's medication as ordered resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +BH118278,50A214,RCF,7/1/2011,"Resident #1 moved into facility on 6/30/11. A dresser and its contents were placed in the back hallway for storage. The dresser and contents are now gone. The facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +BH129015,50A214,RCF,10/24/2011,"Resident #1 was care planned as an elopement risk. On 10/24/11, he/she was found outside of the building with no injuries. During the course of the investigation, it was discovered that the door alarms were malfunctioning. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH120476A,50A214,RCF,7/6/2012,Resident #1 was found restrained to his/her headboard with a scarf when the morning caregiver came in to get him/her up for the day. Resident #1 was screaming to _x001A_get this thing off me immediately_x001A_. He/she was unable to recall anything. Resident #1_x001A_s arms were reddened with indention marks. Reported Perpetrator 3 (RP3) and Reported Perpetrator 2 (RP2) worked the night shift and were the assigned caregivers for Resident #1. RP3 confessed to Law Enforcement that he/she and RP2 had restrained Resident #1 with the scarf. RP2 denied involvement. RP3 was found responsible for wrongful use of a physical restraint of an adult which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Restraints +BH120476B,50A214,RCF,7/6/2012,Reported Perpetrator 2 (RP2) entered Resident #1_x001A_s room at approximately 6:00 a.m. to change his/her depends. Resident #1 was found at 7:15 a.m. restrained to his/her headboard. RP2 failed to assess the situation and provide interventions to prevent Resident #1 from further harm. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Neglect +BH146625,50A214,RCF,4/3/2014,"Resident #1 had a history of inappropriate contact with Resident #2. Resident #1 had two episodes of inappropriate behavior on the same day. Resident #1 kissed Resident #2. Later that day Resident #1 was seen with his/her had in Resident #3's under garments. The facility failed to appropriately service plan Resident #1 for inappropriate behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO14243,50A214,RCF,11/5/2014,"A re-licensure survey completed on November 5, 2014, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to ensure compliance with health care services and regulations. The facility also failed to ensure Resident #1 had a plan in place to keep him/her safe and other residents safe when Resident #1's behaviors escalated. Resident #1 verbally and physically hurt other residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH159848,50A214,RCF,8/23/2014,"Resident #1 was found at the local mall by security due to him/her falling. Resident #1 was transported to the hospital with injuries. Resident #1 had a history of exit seeking. The facility failed to appropriately care plan for Resident #1's exit seeking behaviors and provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH150119,50A214,RCF,1/31/2015,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Both residents had a history of agitation/aggression. The facility failed to appropriately address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH153592,50A214,RCF,3/19/2014,"Resident #1 and Resident #2 were involved in an altercation. Both residents had been involved in a previous altercation and were being monitored. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA106017,50A226,RCF,11/23/2010,RP2 documented that she/he gave Resident #1 her/his prescribed pain medication when she/he did not on at least two occasions. The facility failed to ensure Resident #1's medications were being administered as ordered resulting in the potential for harm.,2,0,,, +BA117247A,50A226,RCF,5/12/2011,RP2 pulled Resident #1's hair during a physical altercation. The facility failed to ensure Resident #1's rights.,2,0,Not Substantiated,Substantiated,Physical Abuse +BA117247B,50A226,RCF,5/12/2011,RP2 was observed yelling and called Resident #1 inappropriate names resulting in the resident becoming very agitated. The facility failed to ensure resident rights.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +BA117796,50A226,RCF,7/23/2011,"The facility failed to adequately address residents' aggressive behavior towards eachother resulting in a physical altercation. Resident #1 sustained minor harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BA117797,50A226,RCF,10/24/2010,The facility failed to administer medication as ordered resulting in the potential for harm. RP2 directed staff to administer Resident #1's medication outside of the medication parameters. No negative outcome was observed.,2,0,,, +CO13032,50A226,RCF,3/22/2013,A Licensed Condition was issued effective 3/29/13 due to continued non compliance with Oregon Administrative Rules and evidenced by preliminary information from survey revisit #3 completed 3/21/13. Please see Condition RCFCD13-004 terms for details.,2,0,,, +BA134582,50A226,RCF,8/29/2013,"Resident #1 was a known fall risk, required full assistance with ambulation and transfers, and was care planned for frequent checks. Resident #1 experienced two falls between August 26 and 28, 2013. 0n August 28, 2013 Resident #1's anxiety medication increased and was observed to have an unsteady gait. At approximately 12:50 AM on August 29, 2013, Resident #1 was discovered on the floor and transported to the hospital for treatment of a fracture hip and brain bleed. The facility failed to appropriately care plan for falls resulting in serious injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,2500,,,Neglect +BA134492,50A226,RCF,7/28/2013,"Resident #1 had a history of aggression and had a prescription for a behavioral cream. Resident #1 hit resident #2 in the face after reportedly being agitated for approximately an hour before the incident. Facility staff did not apply Resident #1's cream until after the incident. Resident #2 had some redness on his/her face. The two residents had a previous altercation, resulting in both residents hitting each other. The facility failed to address a resident's behavior. The failure is a violation of residents rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA134840,50A226,RCF,9/9/2013,"Resident #2 entered Resident #1's room and proceeded to punch in the face resulting in bruising. Resident #2 had a history of wandering and sporadic, violent behavior. The facility failed to adequately monitor resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA145668,50A226,RCF,11/30/2013,"Resident #1 was a known fall risk and was found with an injury of unknown injury on or about 11/30/13. Resident #1 sustained a fall on 12/7/13. The facility failed to conduct a thorough investigation on the unknown injury and failed to address the known fall to determine if additional interventions were needed to prevent future falls. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BA145689,50A226,RCF,12/4/2013,"Resident #1 was a known fall risk and care planned with interventions. Resident #1 experienced three known falls in December. There were no documented changes after the recent falls. The facility failed to monitor and care plan after falls continued. The failures are violation of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +BA145796,50A226,RCF,1/5/2014,RP2 failed to document the administration of a medication on Resident #1's Medication Administration Record. RP3 inproperly administered another dose of the same medication several hours after later. Facility staff were notified and Resident #1 was monitored without incident. The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA147011,50A226,RCF,3/6/2014,"Resident #2 had a history of agitated and aggressive behaviors and was observed to enter Resident #1's room on several occasions. On or about March 6, 2014, Resident #2 entered Resident #1's room and they engaged in a physical altercation. The facility failed to adequately address Resident #2's behavior resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA148129D,50A226,RCF,6/21/2014,Resident #1 was care planned for foot rests while in her/his wheelchair. RP2 did not put the foot rests when transporting Resident #1 on one known ocassion resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA148646,50A226,RCF,7/26/2014,"Resident #1 and Resident #2 both had diagnoses related to cognition and reside in a secure facility. On 7/26/14, Resident #2 wandered into Resident #1's room and attempted to get her/him out of bed resulting in injury to Resident #1. Witness testimony and facility documentation revealed Resident #2 had a history of wandering and disruptive behavior. The facility failed to adequately address Resident #2's behavior resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil money penalty is warranted, however one was not issued due to the current LOA (Letter of Agreement) initiated on December 4, 2014.",3,,,,Neglect +BA149671,50A226,RCF,9/1/2014,The facility failed to ensure an accurate Medication Administration Record for Resident #1 resulting in the potential for harm. Facility staff inaccurately initialed the use of Resident #1's TED when she/he refused it and is a violation of Oregon Administrative Rules.,2,,,, +BA150001A,50A226,RCF,10/6/2014,Complainant reported multiple residents were not being provided with regular incontinence checks resulting in being left in urine soaked depends. Investigative findings determined RP2 failed to consistently provided checks as trained. RP2 was found to be responsible for neglect of care and constitutes abuse. The facility failed to ensure incontinence care and is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +HB117783,50A232,RCF,8/19/2011,RP2 was observed roughly handle Resident #1 when transferring to wheelchair resulting in bruising. The facility failed to protect Resident #1 from rough treatment. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +HB118795,50A232,RCF,12/20/2011,"Resident #2 has a history of behavioral disturbances. Resident #2 is care planned to have his/her door locked to prevent other residents from entering. On December 20, 2011, Resident #1 entered Resident #2_x001A_s unlocked room. Resident #2 began hitting Resident #1. Resident #1 was transported to the emergency room for right hip pain and was diagnosed with a fractured hip. The facility failed to follow the care plan for Resident #2_x001A_s behavior resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,250,,,Neglect +HB129111,50A232,RCF,1/28/2012,"The facility failed to address Resident #1 and Resident #2_x001A_s behaviors resulting in a physical altercation between them. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB129674,50A232,RCF,3/29/2012,"Resident #1_x001A_s liquid narcotic medication was reported unaccounted for or missing. + +The loss of narcotic medications resulted from the actions of an unknown individual. + +The facility failed to provide a safe medication administration system resulting in the loss of resident medications. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +HB120131,50A232,RCF,5/20/2012,Resident #1 insulted Reported Perpetrator 2 (RP2). RP2 responded to Resident #1 with hostile and inappropriate comments that included inappropriate language. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for resident #1. The failure is a violation of Oregon administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HB132808,50A232,RCF,3/29/2013,Resident #1 was found to have two bruises on his/her left leg. Resident #1 reported that Reported Perpetrator 2 (RP2) squeezed his/her leg when providing care and caused the bruises and that it was painful. RP2 denied helping Resident #1 during his/her shift. RP2 signed off on the task sheet that care was provided to Resident #1. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +HB133643,50A232,RCF,7/1/2013,"On 6/3/13 a Hospice chart note indicated that they had spoken to the facility about Resident #1's toenail care. Notes indicated that Hospice had spoken to facility staff eight additional times regarding Resident #1's toenails needing care. Resident #1 did not receive nail care until 7/14/13 when he/she was seen by a podiatrist. The facility failed to obtain timely nail care for Resident #1 causing him/her pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,, +HB134334,50A232,RCF,9/6/2013,"Resident #1, Resident #2 and Resident #3 were involved in an altercation. Resident #1 had previous behavior issues with no noted interventions in his/her service plan. Resident #2 also had previous behavior issues with no noted interventions in his/her service plan. The facility failed to care plan for behavioral interventions or provide staff instruction on behavior issues. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB134363,50A232,RCF,9/10/2013,"Resident #1 returned from a stay with an outside provider. Resident #1 experienced numerous falls upon his/her return to the facility. The facility did not implement any additional interventions for nine days. The facility failed to reassess Resident #1's current status upon return to the facility and implement additional interventions regarding falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,, +HB135285,50A232,RCF,12/4/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #1 sustained a skin tear and bruising on his/her face. Resident #1 did not sustain injury. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB146626,50A232,RCF,3/4/2014,"Resident #1's Care Plan in February 2014, stated his/her implant site was to be cleaned daily and the hardware not re-applied until the area was dry. Neither of the above actions were being implemented by facility staff and an infection was discovered in March, 2014. After unsuccessful treatment; in May, 2014 Resident #1 saw a specialist and the implant site degraded to the point there was a hole through Resident #1's head and the implant could be seen. Reportedly, the hole will never heal. The facility failed to follow Resident #1's Care Plan, resulting in significant injury. The failure is considered neglect of care and constitutes abuse.",4,2500,Substantiated,Substantiated,Neglect +HB148298,50A232,RCF,8/28/2014,"Resident #2, who had a history of wandering and opening doors entered Resident #1's room and got into bed with him/her thinking it was Resident #2's spouse. Resident #1 called for help. Resident #1's sustained an injury to his/her nose. The facility failed to follow Resident #1's service plan regarding keeping his/her door locked. The service plan stated Resident #1's door was to be closed and locked at all times. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB151041A,50A232,RCF,4/23/2015,The facility failed to ensure facility staff followed Resident #1's care plan. Resident #1 was to be re-approached if he/she refused assistance with Peri Care. Facility staff forcefully provided care for Resident #1 instead. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB151041B,50A232,RCF,4/23/2015,"The facility failed to adequately provide a safe environment for Resident #1. Reported Perpetrators #2 and #4 (RP2 and RP4) forced peri care on Resident #1, and Resident #1 sustained several skin tears and bruises. RP2 and RP4 are responsible for physical abuse. The facility's failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +HB150588,50A232,RCF,3/17/2015,"The facility failed to follow Resident #1_x001A_s care plan. Resident #1 was care planned for safety checks every two hours, a crash mat next to the bed, and hip protectors. Resident fell and fractured his/her hip. The crash mat was not in place, and Resident #1 was not wearing hip protectors at the time. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS117069,50A235,RCF,4/21/2011,"Resident #1 was a cognitively impaired resident that required transfer assistance. Staff observed Resident #1 self ambulate on multiple occasions and was a high risk for falls. On April 21, 2011 Resident #1 sustained an injury fall that required transportation to the hospital for treatment of a fracture. The facility failed to adequately care plan resulting in moderate harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC116244,50A236,RCF,1/31/2011,"A Facility staff member began to yell when a resident, whom he/she was having issues with, came near him/her. That upset the resident, which resulted in the resident striking out at the staff member. The staff member gestured as if he/she was going to strike the resident back, but other staff intervened.",2,0,,, +BC129056,50A236,RCF,11/30/2011,Resident #1 was given a dosage of pain medication from Resident #2_x001A_s supply. Resident #1_x001A_s supply was not going to be available for an hour and he/she was in significant pain. There was no documentation that the dose had been borrowed and then replaced. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rule.,2,0,,, +BC129149A,50A236,RCF,11/10/2011,"Resident #1_x001A_s physician ordered that he/she was to be up in a chair one hour, 3 times a day maximum, for meals. The facility failed to implement and follow physician orders. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC129149B,50A236,RCF,11/10/2011,Resident #1 required wound dressing changes. The facility failed to ensure the proper delegation of task was conducted for all staff providing care to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC128987A,50A236,RCF,1/13/2012,"Five residents have unexplained bruising on the back of their hands, wrists and forearms. No specific incidents or person was identified that caused the bruise-like markings. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC128987B,50A236,RCF,1/13/2012,"The facility failed to report potential or suspected abuse, and failed to conduct and document an internal investigation. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC129272A,50A236,RCF,1/17/2012,The facility failed to promptly investigate Resident #1_x001A_s injury of unknown origin. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC129272B,50A236,RCF,1/17/2012,The facility failed to report potential or suspected abuse. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC129222A,50A236,RCF,1/8/2012,"Resident #2 pushed Resident #1 to the floor and kicked him/her. Resident #2 had a history of aggressive behavior. Resident #2_x001A_s behaviors were not addressed in his/her care plan. The facility failed to provide a safe environment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC129222B,50A236,RCF,1/8/2012,"Resident altercations of November 13, 2011 and January 8, 2012 were not reported to APS. Their injuries still remained unexplained by facility investigation. The facility failed to report potential or suspected abuse. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC129460,50A236,RCF,2/2/2012,"It was discovered that Resident #1 had a gangrenous left second toe when he/she was seen by the nail clinic. Staff was to monitor Resident #1 for cleanliness, behavior changes and/or a decline in abilities. The care plan had no instructions for staff if/when Resident #1 refused showers. The facility failed to follow the care plan and monitor Resident #1 for behavior changes and/or a decline in abilities. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC129721A,50A236,RCF,3/8/2012,Resident #1 was found on the floor next to his/her bed. Resident #1_x001A_s physician was notified and responded at 10:24 AM to have Resident #1 sent to the hospital. Resident #1 was not transported until after 3:00 PM. The facility failed to ensure Resident #1_x001A_s prompt delivery to the hospital per his/her physician_x001A_s request. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC129588,50A236,RCF,3/19/2012,"Resident #1 was improperly transferred using a mechanical device. Resident #1 suffered swelling in his/her right leg and was later diagnosed with a right femur fracture at the hospital. The facility failed to properly transfer Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC129591,50A236,RCF,3/20/2012,"Resident #1 had two skin tears to his/her upper arm and a reddened, swollen area on his/her elbow. As part of Resident #1_x001A_s care plan, he/she was to wear long sleeves or Geri-sleeves to prevent skin injuries. Resident #1 was not wearing long sleeves or Geri-sleeves when the injuries were found. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC149561,50A236,RCF,12/11/2014,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 was known to wander into other rooms and could be hard to redirect. Resident #2 had altercations at his/her previous facility and the current facility was aware of history. Resident #1 was transported to the hospital and received staples to close a gash on his/her head. Resident #2 sustained a bite mark and scratches. The facility failed to implement adequate interventions regarding Resident #2 wandering into other resident rooms. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC150019,50A236,RCF,1/16/2015,"Resident #1 eloped from the facility on three separate occasions. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC153451,50A236,RCF,10/21/2015,"The facility failed to perform a urine test in a timely manner, and administer Resident #1's medication as ordered. This failure is a violation of Oregon Administrative Rules.",2,,,, +BC164222,50A236,RCF,12/29/2015,"The facility failed to adequately follow Resident #1's care plan. Resident #2 and Resident #1 have a history of resident to resident altercations. Resident #1 was care planned to be in line of sight of a care giver at all times. Resident #1 went un-observed and got into an altercation with Resident #2. Both residents sustained skin tears as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +AL116038A,50A239,RCF,9/15/2010,"The facility failed to appropriately intervene after Resident #1 entered Resident #2's room and threatened to harm Resident #2. Resident #2 was negatively affected and the wrongdoing was substantiated. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AL116038B,50A239,RCF,9/15/2010,"The facility failed to answer Resident #2's call light in a timely manner on several occasions resulting in incontinence. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AL117207,50A239,RCF,1/5/2011,Resident #1 was care planned as a fall risk and scheduled to be monitored by staff every 15 minutes. Reported Perpetrator 2 had not checked Resident #1 for approximately 40 minutes and found him/her on the floor near the common area. The failure of safety checks contributed to his/her fall.,2,0,,, +AL118668,50A239,RCF,11/23/2011,Resident #1 and Resident #2 had cognitive deficits making communicating their needs difficult. Reported Perpetrator 2 (RP2) was witnessed speaking inappropriately to Resident #1 and Resident #2 resulting in loss of dignity. The facility failed to assure resident rights and provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AL129174,50A239,RCF,9/14/2011,"On 9/14/12, Reported Perpetrator 2 (RP2) signed off on Resident #1's narcotic pain medication but did not actually administer the medication. RP2's failure resulted in Resident #1 suffering unreasonable pain. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +AL129418,50A239,RCF,2/6/2012,Reported Perpetrator 2 (RP2) failed to place socks on Resident #1's feet prior to assisting with transfer as required by the care plan. Resident #1 was found in the common area with a cut to his/her foot from broken glass from a vase. Resident #1's skin injury could have been lessoned if his/her socks were placed on his/her feet. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AL129507,50A239,RCF,1/26/2010,"Reported Perpetrator 2 (RP2) rough handled Resident #1 while pushing him/her in the wheelchair and grabbed his/her wrist roughly until skin looked visibly ""twisted."" RP2 is responsible for physical abuse by rough handling Resident #1. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +AL129639,50A239,RCF,12/15/2011,"Reported Perpetrator 2 (RP2) failed to ensure Resident #1's chair alarm was attached to his/her chair as care planned. Fifteen minutes after RP2 last checked on Resident #1, he/she was found on the floor with no injuries. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AL129658,50A239,RCF,2/24/2012,Reported Perpetrator 2 (RP2) failed to administer Resident #1's narcotic as need pain medication when the over-the-counter pain medication did not relieve the pain and his/her pain continued. RP2 was neglectful in following medication orders resulting in Resident #1 suffering continued pain. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Neglect +AL129781,50A239,RCF,10/31/2011,"Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan requiring separation from Resident #2, resulting in an altercation of Resident #1 punching Resident #2. Evaluation noted no injuries. RP2 failed to follow the care plan. The facility failed to ensure the care plan was followed and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +AL120470,50A239,RCF,3/23/2012,"Resident #1 climbed out a window on 3/23/12 and sustained bruising to his/her arm and hand. He/she climbed out a window on again 5/5/12. The facility failed to follow the care plan and monitor Resident #1. The facility failed to assure Resident #1 was safe due to his/her exit seeking behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AL120575,50A239,RCF,5/15/2012,"On 5/15/12, cotton briefs belonging to a person of the opposite sex as Resident #1, was found lying on his/her chair in his/her room. On 5/17/12, Resident #1 recalled the same and stated the other resident asked Resident #1 to remove his/her own undergarment. Resident #1 had no prior reporting of this nature before. There were no noted injuries to him/her. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AL120695,50A239,RCF,5/22/2012,"Resident #1 had a pattern of wandering into other resident rooms and required staff to monitor for this behavior and redirect. On 5/22/12, Resident #2 came out of his/her room and stated Resident #1 was unclothed in his/her bed. Resident #2 stated Resident #1 ""touched his/her bottom""; however there were no injuries to Resident #2. The facility failed to monitor Resident #1 and failed to provide a safe environment for Resident #2. The failures are a violation of Oregon Administrative Rules.",2,0,,, +AL120733,50A239,RCF,6/30/2012,"The facility failed to follow Resident #1's care plan to have a motion detector on his/her door due to wandering and sexual behaviors. He/she was found naked in Resident #2's bed and Resident #2 was disturbed. Resident #1's motion detector was turned off. The facility failed to follow the care plan and failed to provide a safe environment. The failures are a violation of resident rights, are considered neglect resulting in sexual exploitation and constitute abuse. + + + +The facility had a change of ownership on 7/18/12; therefore a civil penalty will not be issued due to this incident occurring beforehand.",3,0,,,Sexual abuse +AL121720,50A239,RCF,7/1/2012,"Resident #1's service plan indicated the need for a second caregiver to assist with his/her care whenever he/she was combative or resistive to care. On 7/1/2012, Reported Perpetrator 2 (RP2) failed to follow the service plan when Resident #1's behaviors were combative and resistant to care. Resident #1 suffered self-inflicted skin tears from his/her own fingernails. RP2 is found responsible for neglect of care, which constitutes abuse. The facility failed to provide a safe environment and ensure Resident #1's service plan was followed. The failures are a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +AL146636,50A239,RCF,10/13/2013,"Resident #1 was able to leave the facility through an unlocked gate that leads to the parking lot of the facility. The facility failed to provide a safe environment by allowing the resident to leave through an unlocked gate, and adequately monitor Resident #1 given his/her propensity to wander. These failures are a violation of resident Rights, and Oregon Administrative Rules.",2,,,, +AL146661,50A239,RCF,3/18/2014,Reported Perpetrator 2 (RP2) slapped the Resident #1's hand in reaction to Resident #1 pinching/poking RP2. The actions of RP2 constitute physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +AL147232,50A239,RCF,12/23/2013,"Resident #2 had a history of wandering the facility hallways and entering other residents' rooms and was care planned to be redirected when observed wandering. Resident #1 was a private person whom becomes agitated when other residents enter his/her room. On 12/23/14, it was discovered Resident #2 and Resident #1 had a physical altercation. The facility failed to ensure his/her care plan was followed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL146678A,50A239,RCF,3/16/2014,The facility failed to ensure Resident #1 was spoken to respectfully and with dignity. The failure is a violation of resident rights and is a violation of Oregon Administrative Rules.,2,,,, +AL146678B,50A239,RCF,3/16/2014,Resident #3 and Resident #2 had a physical altercation. Resident #2 had a scratch on his/her neck but didn't require medical attention. Resident #3 was known to have violent behaviors. The facility failed to implement interventions regarding Resident #3's behaviors to ensure a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL148450,50A239,RCF,3/3/2014,"Resident #1 was administered the incorrect does of narcotic pain medication, two separate times; however he/she had no ill effects. The facility failed to administer his/her medications as ordered and the failure is a violation of Oregon Administrative Rules.",2,,,, +AL149021,50A239,RCF,3/8/2014,"Resident #1 and Resident #2 were cognitively impaired and both independently mobile. Resident #2 frequently wandered into other residents' room and was to be monitored and redirected if noted. On 3/8/14, both were found sitting in another residents' room and both had injuries to their face. The facility failed to follow Resident #2's care plan to ensure a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL159851,50A239,RCF,10/22/2014,"Resident #3 had noted history of wandering through the building and into other residents' apartments. His/her care plan stated to observe him/her attempting to enter other residents' apartments and if noted to redirect him/her for altercation prevention. Resident #1 was found on the floor in Resident #2's room where Resident #3 had been found sleeping in Resident #2's bed. Resident #3 and Resident #1 had an altercation. Resident #1 was transported to the hospital and diagnosed with a hip fracture. The facility failed to monitor and redirect Resident #3 for wandering as noted in his/her care plan. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL150865,50A239,RCF,7/25/2014,"Resident #2 was known for aggressive and violent behaviors. Resident #2 pushed Resident #1 down. Resident #2 was wandering in Resident #1's room at the time Resident #1 was found sitting on the floor. The facility failed to care plan and implement effective interventions regarding Resident #2's behaviors to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +AL151290,50A239,RCF,8/13/2014,"Resident #1 was found walking about a half-mile from the facility and was located at an intersection that meets with a US highway. He/she had not been exit seeking, but did wander. An investigation revealed that the gate had been left unlatched by the landscaping crew and there were missing boards from the fence that allowed for a gap wide enough for him/her to possibly squeeze between the slats. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.",2,,,, +AL151434,50A239,RCF,8/17/2014,"Resident #2 had a history of wandering into other residents' rooms and was care planned for staff to observe for wandering and redirect for altercation prevention. Resident #1's care plan required staff to redirect any resident from entering his/her room to prevent altercations. On 8/17/15, Resident #2 was found on the floor after entering Resident #1's room. No injuries noted. The facility failed to follow their care plans to ensure a safe environment. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +AL151908,50A239,RCF,11/14/2014,"On 11/17/14 at approximately 7:30am, Reported Perpetrator 2 (RP2) got into a physical altercation with Resident #1. RP2 hit Resident #1 with his/her cane, slapped him/her, and pushed him/her from a standing position to the floor. Resident #1 sustained a skin tear. RP2's actions are considered physical abuse. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Physical Abuse +AL151919,50A239,RCF,12/10/2014,"The facility failed to implement and care plan interventions regarding Resident #1's wandering behavior. Resident #1 wandered into Resident #2's room and resulted in an altercation. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +AL151923,50A239,RCF,12/19/2014,"Resident #1 had a history of wandering into other residents apartments and was care planned for staff to observe and redirect him/her from going into other resident rooms for altercation prevention. Resident #1 was found in Resident #2's room where an altercation occurred. Resident #1 sustained a fractured hip. The facility failed to follow Resident #1's care plan to ensure safety. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB129564,50A244,RCF,3/18/2012,"Resident #1 had a history of aggressive behavior and was on medication to treat her/his anger/anxiousness. On or about March 18, 2012, Resident #1 pushed Resident #2 down. Resident #2 experienced pain and was transported to the hospital where she/he was treated for a fracture. The facility failed to address Resident #1 aggressive behavior resulting in moderate harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +HB133189A,50A244,RCF,5/10/2013,Resident #1's clothing was laundered by the facility. Some clothing and socks were missing from Resident #1's residence and were not accounted for by the facility. The facility failed to provide appropriate housekeeping services. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB148595,50A244,RCF,9/17/2014,"On or about September 17, 2014, Resident #1 engaged in a physical altercation that caused bruising to Resident #2. Witness testimony and facility documentation revealed Resident #1 experienced multiple altercation with other residents. The facility failed to ensure a safe environment to adequately address Resident #1's negative behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL129150,50A253,RCF,1/5/2012,Resident #1 was found upset and with scratches to both sides of his/her face and chin. The facility failed to report the potential or suspected abuse. The failure is a violation of Oregon Administrative Rule.,2,0,,, +AL149443,50A253,RCF,4/27/2014,"Resident #2 entered Resident #1's room. When Resident #1 told Resident #2 to leave his/her room, Resident #2 pushed Resident #1 out of his/her wheelchair. Resident #1 was found on the floor with injuries and transported to the hospital. Resident #2 has a history of wandering into other residents' rooms. The facility failed to implement adequate interventions regarding Resident #2 wandering into other residents' rooms. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL149607,50A253,RCF,5/23/2014,"Resident #1 and Resident #2 were involved in an altercation in Resident #2's room. Resident #2 was transported to the hospital and treated. Resident #1 had a history of wandering into other resident rooms. The facility failed to implement adequate interventions regarding Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AL150932,50A253,RCF,8/4/2014,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained an injury to his/her eye. Resident #1 had a history of aggression toward staff and other residents. Resident #2 also had a history of aggression. The facility failed to implement appropriate interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL149488,50A253,RCF,8/14/2014,Resident #1 wandered into Resident #2_x001A_s room which started an altercation. Resident #1 sustained scratches on his/her neck. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL151297,50A253,RCF,10/11/2014,"Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure that Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL154060,50A253,RCF,9/6/2015,"Resident #1 was found in Resident #2's room. Resident #2 had a history of attempting to get residents of the opposite sex into his/her bed. Resident #1 had a skin tear on his/her arm. Resident #1 sustained another skin tear to his/her arm due to Resident #2 grabbing him/her when being redirected by staff. The facility failed to care plan appropriately and implement interventions regarding Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL153840B,50A253,RCF,11/2/2015,"Resident #1's care place was updated requiring staff to lay him/her down if he/she was slumped in his/her wheelchair or at the table. Resident #1 was found on the floor of the dining room. He/she sustained bruising to his/her forehead. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL150384,50A253,RCF,2/18/2015,"Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL151934,50A253,RCF,1/9/2014,"Resident #1 had a history of aggression and being resistive to care. On January 4, 2016, Resident #1 became combative and violent with staff and residents. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL151942,50A253,RCF,2/13/2015,"Resident #1 and Resident #2 were involved in an altercation when Resident #1 entered Resident #2's room. Resident #1 hit Resident #2 in the mouth resulting in Resident #2 sustaining a cut lip and knocking out two teeth. Resident #1 and Resident #2 had a history of behaviors. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL153335A,50A253,RCF,10/12/2015,"Resident #1 lost a significant amount of weight during a four month period. + +The facility failed to assess Resident #1 for a change of condition and service plan accordingly. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL164226,50A253,RCF,1/7/2016,As a safety precaution Resident #1 used a breakaway belt to secure him/her in their wheelchair. Staff forgot to secure the belt and Resident #1 fell out of the wheelchair. He/she sustained a rug burn above his/her eyebrow. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL153839,50A253,RCF,10/27/2015,Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL151954,50A253,RCF,3/7/2015,"Resident #2 entered Resident #1's room and had him/her in a choke hold. Both residents sustained bruising. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL151975,50A253,RCF,5/4/2015,"Resident #1 had been exhibiting behaviors and when staff tried to redirect, he/she became violent. 911 and paramedics were called to the facility and Resident #1 was transported. The facility failed to appropriate care plan Resident #1 for his/her behaviors and give direction to staff. The facility also failed to appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +AL153167A,50A253,RCF,9/24/2015,"Resident #1 was found in his/her room sitting on the bed, wearing no pants or underwear with a used adult diaper in his/her mouth. Resident #1's room smelled of urine due to used diapers and urine soaked clothing lying about the room and closet. The facility failed to follow Resident #1's care plan and appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",21,,,,Neglect +AL153167B,50A253,RCF,9/24/2015,Resident #1 had a CPAP machine that was to be used when he/she was admitted to the facility. The facility never contacted Resident #1's physician to obtain an order nor did they provide the unit to Resident #1. The facility failed to provide or maintain resident care equipment. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL153167C,50A253,RCF,9/24/2015,"Resident #1 appeared with a grapefruit size bruise on his/her left hip. Facility staff were unable to determine how the injury occurred. There was no documentation regarding the injury. The facility failed to provide a safe environment and report to APS. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,, +AL153167D,50A253,RCF,9/24/2015,Resident #1 had swelling in his/her feet and legs. His/her care plan stated the facility nurse would communicate Resident #1's care needs with family. The facility failed to communicate with family regarding Resident #1's medical needs. The facility failed to follow Resident #1's care plan. The failures are a violation of Oregon Administrative Rules.,2,,,, +DL117763,50A262,RCF,8/18/2011,RP2 was verbally inappropriate with Resident #1 and Resident #2 while providing care. The facility failed to protect residents from verbal abuse and is a failure of Oregon Administrative Rules. RP2 was held responsible for verbal abuse.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +DL134235,50A262,RCF,8/17/2013,"Resident #1 became agitated and combative during personal cares. Reported Perpetrator 2 (RP2) dropped a clean, opened attends over Resident #1's face and removed it immediately. A witness stated they believed it was done to antagonize Resident #1. The facility failed to provide a safe environment to Resident #1. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD105752,50A263,RCF,9/30/2010,The Facility was found to consistently order Resident #1's medication late. It was also determined that staff was not administering the correct and accurate amount of the resident's prescribed liquid medication.,1,0,,, +RD116518A,50A263,RCF,2/6/2011,A resident of the Facility did not receive enough of his/her PRN (as needed) medication when staff administered the medication. The resident's medication was sent from the pharmacy in such a way that it took two pills to meet the physician's order. The staff member who administered the medication only gave the resident one pill. The resident did not experience any negative outcome as a result of not receiving the correct amount of medication.,1,0,,, +RD116518B,50A263,RCF,2/6/2011,"Two residents of the Facility failed to receive ordered medications. One of the resident's MAR (Medication Administration Record) had indicated a medication was administered when it remained in it's packaging, and another resident's MAR did not indicate why the ordered medication wasn't administered. Neither resident experienced a negative outcome as a result of not receiving his/her medication.",1,0,,, +RD116518D,50A263,RCF,2/6/2011,"It was discovered that a resident's low blood sugar reading was not appropriately handled by a Facility staff member. The resident's blood sugar reading was below a set parameter, requiring additional action by the staff member. No additional action was taken following the low reading, placing the resident at risk of harm due to his/her frail medication status.",2,0,,, +RD116723,50A263,RCF,12/26/2010,A resident of the Facility was discovered to be getting sprayed in the face by a Facility staff member while the staff member was assisting the resident with bathing. Other staff heard the commotion in the bathroom and entered. The staff member voluntarily resigned his/her position following the incident.,1,0,,, +RD117454,50A263,RCF,6/8/2011,"A resident of the Facility was able to walk out of the Facility. Upon inspection of the door alarm, staff found another resident nearby. That resident was redirected, however it was not apparent to staff at the time that another resident had left the building.",1,0,,, +RD117469,50A263,RCF,6/6/2011,"Resident #1 is incontinent and care planned accordingly. Staff were to back away and reapproach every few minutes if Resident #1 became aggressive or combative during toileting. On June 6, 2011, staff did not return and clean up RV_x001A_s wheelchair and room until the unsanitary environment was pointed out to them several hours later. The facility failed to provide adequate hygiene. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RD117570,50A263,RCF,6/28/2011,The facility failed to ensure Resident #1's service plan was followed resulting in increased agitation and aggressive behavior. RP2 and RP3 were apportioned abuse.,1,0,Not Substantiated,Substantiated,Verbal/Mental abuse +RD117614,50A263,RCF,7/13/2011,The facility failed to follow Resident #1's Service Plan resulting in successfully eloping from the facility for at least 40 minutes without the facility's knowledge. Resident #1 was returned to the facility without harm. The failure is a violation of OARs.,2,0,,, +RD128902,50A263,RCF,12/3/2011,"It was discovered that Resident #1_x001A_s blood sugars were taken inaccurately between November 10, 2011, and December 3, 2011. There was no observable negative effect as a result of the error. The facility failed to provide a safe medication and treatment administration system. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RD120774,50A263,RCF,6/29/2012,"Reported Perpetrator 2 (RP2) was giving Resident #1 his/her crushed medications in a cup of cocoa when an exit door alarm sounded. RP2 left Resident #1 unattended to respond to the alarm. Witness #2 found Resident #1 choking on the mixture. Resident #1_x001A_s service plan states staff attention while resident takes medications. The facility failed to have a safe medication administration system and follow Resident #1_x001A_s service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RD133632,50A263,RCF,6/12/2013,Resident #1 pushed Resident #3 who fell down and then punched Resident #2 who fell down. Resident #2 sustained a skin tear and bruising on his/her arm. Resident #3 did not sustain injury. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD134024,50A263,RCF,7/24/2013,"Resident #1 was a fall risk and had falls with no amendments to his/her care plan. Resident #2 experienced behaviors and had several altercations with other residents with no amendments to his/her care plan. Resident #1 was found on the floor with Resident #2 trying to help him/her up. No one witnessed the incident. Resident #1 sustained a hip fracture. The facility failed to appropriately care plan for Resident #1 and Resident #2. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD146015,50A263,RCF,2/2/2014,"Pain patches were discovered missing within hours of being applied on Resident #1, Resident #2 and Resident #3. Reported Perpetrator 2 (RP2) admitting taking the resident_x001A_s pain patches. RP2 was found responsible for theft of narcotic pain patches which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BO147467,50A263,RCF,5/4/2014,"Resident #2 hit Resident #1 in the mouth. Resident #1 was transported to the hospital due to the injury. The facility failed to adequately address Resident #1 and Resident #2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD148343,50A263,RCF,7/7/2014,"Resident #1 had a history of falls. Resident #1 sustained a fall in which he/she hit his/her head on 7/8/14. Resident #1 complained of pain until 7/15/14 when he/she was transported to Urgent Care where multiple fractures were found. Resident #1's physician was not contacted nor was emergency personnel called. No instructions or interventions were documented regarding preventing or lowering the risk of falls. The facility failed to update Resident #1's service plan to adequately address fall interventions and assess Resident #1 for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,300,,,Neglect +RD148570,50A263,RCF,8/24/2014,It was discovered that Resident #1 and Resident #2 were missing their pain patches. The patches are applied and then tape is applied over the patch and then the tape is initialed and dated. An unknown individual was determined to be responsible for the theft of medication patches which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RD148968A,50A263,RCF,9/24/2014,"Reported Perpetrator 2 (RP2) was assisting Resident #1 with personal care. Resident #1 was resistant and clenched his/her fists and threatened to hit staff but did not attempt to hit anyone. RP2 attempted again to assist RV, resulting in RV being hurt. RV's Care Plan stated staff was to let RV rest and re-approach if he/she was resistant to care and to give RV plenty of space (10 feet). RP2 was found responsible for neglect of care, which is considered abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +RD148968B,50A263,RCF,9/24/2014,Resident #2 was having incontinence episodes and Reported Perpetrator 2 (RP2) was witnessed being verbally abusive to Resident #2 regarding the incontinence. RP2 was also witnessed taking video of Resident #2. The unauthorized video was then posted to an online social media site. RP2's actions are a violation of resident rights and constitute verbal abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RD149521A,50A263,RCF,12/6/2014,"Resident #1 was found on the floor with a full catheter bag and dried feces on his/her back. Resident #1's service plan stated that he/she required frequent checks due to him/her trying to self-transfer. Catheter care was also in the service plan. Reported Perpetrator 2 (RP2) did not perform frequent safety checks, did not check Resident #1's brief and did not empty catheter bag or seek assistance from other staff. RP2 was found responsible for neglect which constitutes abuse. The facility failed to assure appropriate care for Resident #1. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +RD149521B,50A263,RCF,12/6/2014,Resident #2 was found in the early morning hours in bed without any covers and still wearing his/her clothing and shoes from the day before. He/she was also soaked in urine. Reported Perpetrator 2 (RP2) was responsible for Resident #2's care including frequent checks and assistance with brief changes. RP2 was found responsible for neglect which constitutes abuse. The facility failed to assure appropriate care for Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +RD149675,50A263,RCF,12/17/2014,"Resident #1 was service planned for two showers per week. Between November 20, 2014 and December 18, 2014, Resident #1 only received four showers. The facility failed to follow Resident #1's service plan regarding showers which resulted in inadequate hygiene. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD149676,50A263,RCF,11/5/2014,"Resident #1 did not receive three of his/her 8:00 p.m. medications between October 10, 2014 and November 4, 2014. Resident #1 did not experience any negative outcome. The facility failed to administer Resident #1's medications per physician's orders. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD150312,50A263,RCF,1/19/2015,"Resident #1 had a history of agitation and striking other residents and staff. On the evening of January 18, 2015, Resident #1 was increasingly agitated. Resident #1 was also involved in an altercation with Resident #2. Resident #1 was found the next morning with injuries from an unknown cause. The facility failed to implement adequate interventions to address Resident #1's behaviors. The failure is a violation resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD151683,50A263,RCF,6/18/2015,The facility failed to adequately monitor Resident #1 in relation to his/her elopement risk. Resident #1 was able to leave the facility without staff knowledge. This failure is a violation of Oregon Administrative Rules.,2,,,, +RD152536,50A263,RCF,8/10/2015,The facility failed to adequately care plan in relation to Resident #1's elopement behavior. Resident #1 had a history of leaving the facility and walking to a previous residence. Resident #1 was able to leave the facility without facility staff knowledge and walked home again. This failure is a violation of Oregon Administrative Rules.,2,,,, +RD152545,50A263,RCF,8/7/2015,The facility failed to maintain and adequately safe medication administration system. Resident #1's medication was not filled by the facility in a timely manner. Resident #1 missed several doses of medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +RD153299A,50A263,RCF,10/8/2015,"The facility failed to treat Resident #1 and Resident #2 with dignity and respect. Facility staff brushed Resident #1's teeth against their will, and physically escorted Resident #2 to a bathroom against their will. This failure is a violation of Oregon Administrative Rules.",2,,,, +RD153299B,50A263,RCF,10/8/2015,"Resident #1 was care planned for two person assist with transfers. Reported Perpetrator #2 (RP2) attempted to transfer Resident #1 alone and Resident #1 sustained a skin tear. RP2 is responsible for neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +RD153817,50A263,RCF,5/15/2015,"Resident #1 had money taken form his/her back account on several occasions. The money was taken by Reported Perpetrator#2 (RP2) and RP2 person is responsible for theft, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES104759,50M004,RCF,7/6/2010,"The Facility failed to adequately evaluate, assess and put interventions in place to avoid significant skin breakdown with Resident #1. As a result of the Facility_x001A_s failure, the residents condition worsened and eventually was sent to the hospital, where his/her condition was considered terminal. The resident passed away as a result of his/her unaddressed skin breakdown at the Facility.",4,2500,,,Neglect +ES105739,50M004,RCF,11/25/2010,"The Facility failed to follow physician orders related to Resident #1 receiving a mechanical soft diet. The resident was served meat that was cut up and contributed to the resident choking to death. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,2500,,,Neglect +ES121254,50M004,RCF,10/4/2012,"Resident #1 was in a verbal argument with Reported Perpetrator 2 (RP2) with Resident #1 swearing at RP2. RP2 responded by swearing at Resident #1. At some point, Resident #2 came into the common area not wearing pants and had an incontinent episode on the furniture. Reported Perpetrator 3 (RP3) swore at and belittled Resident #2. Both incidents were recorded. RP2 and RP3 were found responsible for verbal abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +ES120893,50M004,RCF,8/22/2012,Reported Perpetrator 2 (RP2) had been acting and making aggressive statements to residents since early August 2012. Resident #2 was fearful due to verbal threats made to him/her by RP2. The facility did not limit RP2's access to the facility or the residents until late August. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES133396,50M004,RCF,6/4/2013,Resident #1 was admitted to the facility on 5/26/13 from the hospital as an emergency admit. Resident #1 was admitted without physician orders for medications and treatments resulting in Resident #1 self managing his/her own medications. The facility failed to assess Resident #1 to assure his/her ability to safely self-administer his/her medications. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES145996,50M004,RCF,2/3/2014,Resident #1 was exhibiting behaviors such as wandering into resident rooms and outside. Resident #1 was sat on the floor as an intervention due to his/her inability to rise from a seated position on the floor. The facility failed to properly use a restraint and train staff regarding the use of restraints. The failures are a violation of Oregon Administrative Rules.,2,,,, +CO14136,50M004,RCF,6/4/2014,"The Facility failed to provide effective administration oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed June 4, 2014 (Y42T11).",3,,,,Neglect +ES145836C,50M004,RCF,1/1/2014,Resident #1 did not receive his/her medications for two days due to the prescription not being refilled. The facility failed to administer Resident #1's medications as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES133865,50M004,RCF,5/1/2013,"Prior to Resident #3's admission, the facility received information that he/she had previously engaged in sexually inappropriate behavior toward other residents. No care planning was done regarding Resident #3's sexual behaviors. Resident #1 and #2 were negatively affected by Resident #3's behaviors. No incident reports were created and the incidents were not reported to APS. The facility failed to care plan appropriately and implement interventions regarding Resident #3's sexual behaviors and report the incidents to APS. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse",4,2500,,,Sexual abuse +ES145835,50M004,RCF,1/21/2014,"Resident #2 had a previous history of sexually abusing other residents. The facility had care planned for staff to know Resident #2's whereabouts at all times. He/she was left alone in the living room. During which time, he/she touched Resident #1 in a sexually inappropriate way. Resident #1 was negatively affected by Resident #2's behaviors. The facility failed to follow Resident #2's care plan and appropriately care plan for Resident #2's sexual behaviors. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse.",4,2500,,,Sexual abuse +CO15054,50M004,RCF,3/11/2015,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed on August 18, 2015 (DJR912).",3,,,,Neglect +ES150206C,50M004,RCF,2/3/2015,Resident #3 had severe food allergies. The list of foods Resident #3 is allergic to is extensive. Resident #3 was given a food that contained an ingredient that he/she was allergic to. The facility failed to assure Resident #3 was not given food he/she was allergic to. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES150984,50M004,RCF,4/2/2015,Resident #1 had a medication discontinued when there was no physician's order to do so. Resident #1 did not suffer any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES151027B,50M004,RCF,4/20/2015,It was reported that Reported Perpetrator 2 (RP2) told Resident #1 to shut up. The facility failed to assure resident rights and provide staff with appropriate training. The failures are a violation of Oregon Administrative Rules.,2,,,, +ES150625,50M004,RCF,3/15/2015,"Resident #1 became dizzy and fell. There was no notification to the RN, alert charting, temporary service plan, notification to the doctor or notification to the administrator. Resident #1's care plan was out of date and should have been reviewed 2/19/15. The facility failed to assess Resident #1 for a change of condition and care plan accordingly. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES151438,50M004,RCF,5/31/2015,"Resident #1 was admitted to the facility while on probation for assault and the facility had this information. Resident #1 had several incidents of aggressive and threatening behavior toward Resident #2. Resident #2 felt frightened and did not feel facility staff could protect him/her. The facility failed to implement appropriate interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES151695,50M004,RCF,6/11/2015,"Resident #1's care plan states to check him/her for an infection when he/she is aggressive. Resident #1 began showing signs of adverse behavior around June 11, 2015. Resident #1's physician was not notified for approximately twenty days after an infection was suspected. The facility failed to follow Resident #1's care plan regarding infections. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES151881,50M004,RCF,7/8/2015,The facility received a physician's order for Resident #1 to perform a procedure. The procedure was not done in a timely manner. The facility failed to provide appropriate care for Resident #1 by not following his/her physician's order. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES151403,50M004,RCF,5/11/2015,"Medication errors were made on three residents. Due to medication errors Resident #1 experienced restlessness at night and hip pain. Resident #2 was not given his/her pain medication according to physician's order. Resident #3 was not given the appropriate amount of his/her medication. The facility failed to maintain a safe medication administration system. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES151441,50M004,RCF,5/28/2015,Resident #1 and Resident #2 both had a history of aggressive behaviors. A temporary service plan was in place that instructed staff to intervene and keep these residents separated. The facility failed to follow the service plan for Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES152259,50M004,RCF,7/27/2015,"Resident #1 strangled Resident #2 with both hands. Resident #2 sustained an injury. Resident #1 had a history of altercations with other residents. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes",2,,,,Neglect +ES152224,50M004,RCF,5/5/2015,Pills were found on the floor of Resident #1 and Resident #2's room. Pills were also found in Resident #3's room. The facility believed Resident #3 had brought pills in after visiting a friend. There were no adverse effects to the residents. At that time the facility did not have clear policies in place when unknown medication was found in a resident room or on the floor. The facility now has policies in place. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES150456A,50M004,RCF,3/2/2015,The facility failed to provide adequate care for Resident #1. His/her bed was found wet in the evening. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES150456B,50M004,RCF,3/2/2015,"Resident #1 had minimal mobility problems and he/she had several skin breakdown issues. Resident #1's care plan stated he/she was to be checked on every two hours. The facility failed to follow Resident #1's care plan resulting in skin breakdown. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES164705,50M004,RCF,2/19/2016,Resident #1 did not receive a prescribed medication for nine days due to the facility not having it in stock. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO11121,50M011,RCF,11/17/2011,"The preliminary findings of the Residential Care Facility Survey conducted November 15-17, 2011, determined that the Facility was not in substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility_x001A_s noncompliance placed residents at harm and risk for serious harm. The failures are a violation of resident rights, are considered neglect and constitute abuse. Preliminary findings include but are not limited to: + + + +_x001A_Facility Administration + +_x001A_Resident Rights and Protections + +_x001A_Abuse Reporting and Investigation + +_x001A_Resident Move-In and Evaluation + +_x001A_Service Plan - General + +_x001A_Resident Health Services + +_x001A_Staffing Requirements and Training",3,0,,,Neglect +JD118606,50M011,RCF,9/29/2011,The facility failed to follow the care plan to arrange needed doctor appointments when Resident #1_x001A_s health began declining on 9/16/11. The facility failed to timely assess and intervene; and failed to provide an RN assessment when his/her condition changed. Resident #1 was admitted to the hospital on 9/29/11 for treatment discovering serious diagnoses.,4,450,,,Neglect +JD118657,50M011,RCF,9/25/2011,Resident #1's medication was not available at needed prescribed time and medication was administered outside time interval parameters of his/her PRN medication. The facility failed to have a safe medication system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +JD129439B,50M011,RCF,2/15/2012,"The facility failed to timely assess Resident #1's signs and symptoms of a possible urinary tract infection for approximately eight days. Resident #1 tested positive and was placed on antibiotics. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +JD129443A,50M011,RCF,11/30/2011,The facility failed to consult with the facility RN regarding Resident #1's reported medical concern. The failure is a violation of Oregon Administrative Rules.,2,0,,, +JD129447,50M011,RCF,9/22/2011,Resident #1 was administered 1/2 tab of a 30 mg elapsed pain medication as substitute for 15 mg elapsed pain medication without documented physician authorization. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +JD129425A,50M011,RCF,9/20/2011,The facility failed to administer medications as ordered for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,,Neglect +JD129425B,50M011,RCF,9/20/2011,The facility failed to follow physician's orders for Resident #1 to be seen within one week of hospital discharge. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO12084,50M011,RCF,8/1/2012,Revocation effective 9/24/2012,3,0,,,Neglect +JD120048,50M011,RCF,2/15/2012,The facility failed to correct improper billing practices in a timely manner.,2,0,,, +JD120781,50M011,RCF,7/16/2012,"The facility failed to intervene when Resident #1 experienced a significant change of condition on 7/16/12. On 7/18/12, he/she was transported to the hospital and diagnosed with a fractured hip and pelvis. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +A civil penalty is warranted for this incident; however one will not be issued due to the date of receipt in central office was after the license was revoked on 9/24/12.",3,0,,,Neglect +JD120782,50M011,RCF,7/18/2012,"Resident #1 was transported to the hospital for lethargy and fever. Two state 2-3 ducubitus ulcers were discovered. The facility failed to assure timely medical treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +A civil penalty is warranted for this incident; however one will not be issued due to the date of receipt in central office was after the license was revoked on 9/24/12.",3,0,,,Neglect +JD121033,50M011,RCF,8/14/2012,"Resident #1 had a history of skin breakdown and reponsitioning in bed was required; however he/she suffered a decubitius ulcer on the right coccyx. The facililty failed to provide care. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +JD121142,50M011,RCF,8/10/2012,Resident #1's skin concerns were identified and treated appropriately.,0,0,,, +JD121220B,50M011,RCF,8/17/2012,Resident #1 was dependent for grooming and hygiene and was to receive sponge baths; however no documentation of sponge baths given and was not on the shower schedule. Resident #1 experienced poor hygiene with odors. The facility failed to provide care to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +JD121130,50M011,RCF,8/20/2012,"The facility failed to provide a safe medication administration system and failed to have medication available for Resident #1. He/she was without his/her ordered pain medication for approximately five days. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +JD121419,50M011,RCF,9/13/2012,The facility failed to provide service to Resident #1 resulting in poor continuity of care. He/she was discovered with a foul body odor; there were no hygiene supplies in his/her shower; and he/she experienced recurring fungal infections there were treated for approximately five month with external/internal medications. The facility failures are a violation of Oregon Administrative Rules.,2,0,,, +JD121421,50M011,RCF,9/17/2012,"The facility failed to provide a safe environment and failed to seek timely medical treatment for Resident #1 regarding his/her falls and pain. On 9/13/2012, Resident #1 transferred to a new facility and he/she requested emergency medical assistance due to his/her pain. Resident #1 was diagnosed with a fractured pelvis. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incidents warrants a civil penalty; however due to the fact that the facility is no longer licensed, a civil penalty will not be issued.",3,0,,,Neglect +WB105972,50M019,RCF,12/19/2010,"Resident #1 was care planned as non ambulatory with two person transfer and was discovered with bruising and swollen clavicle. Witness testimony determined injuries were consistent with an improper transfer. The facility failed to ensure Resident #1's service plan was followed regarding proper transfer techniques resulting in harm to Resident #1. No documented internal investigation was conducted surrounding the incident. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +WB117458,50M019,RCF,7/14/2011,The facility failed to provide a safe environment resulting in the loss of multiple residents' belongings. An unknown person was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +WB120607,50M019,RCF,7/20/2012,Several residents reported RP2 was verbally abusive towards them causing unreasonable emotional discomfort and fear. Internal investigation was conducted and RP2 was suspended. The facility failed to protect residents from verbal abuse. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for verbal abuse.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +WB120640,50M019,RCF,7/23/2012,"Resident #1 has a diagnosis related to cognition and resides in a secure facility. Staff took Resident #1's rings off and placed them in an unsecure spot. The rings were later discovered missing. The facility failed to provide a safe environment resulting in the loss of three rings from Resident #1. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse.",3,250,,,Neglect +WB120966,50M019,RCF,8/14/2012,"Resident #1 had a wound with orders to cleanse twice daily. Resident #1 was discovered with maggots in her/his wounds on or about August 14, 2012. The facility failed to ensure adequate wound cleansing. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation date and when it was closed.",2,,,,Neglect +WB146590,50M019,RCF,3/27/2014,"Resident #1 was assisted by a caregiver to the ground after her/his knee's buckled. Resident #1 reported pain in her/his left arm/shoulder, thumb and left knee and was transported to the hospital for an evaluation. Facility determined the bruise on her/his stomach was due to her/his dog. Investigation concluded that the new caregiver used an improper technique to assist the resident and was retrained. The facility failed to assure a qualified caregiver was present. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +WB147552,50M019,RCF,5/20/2014,"Resident #1 has a condition related to memory and was a known fall risk that required assistance with mobility. On or about May 20, 2014 experienced an injury fall after attempting to abulate on her/his own. The facility failed to adequately care plan resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +WB147390,50M019,RCF,6/9/2014,"Resident #1 was discovered on the floor in her/his room and transported to the hospital for treatment of a right scapular fracture and urinary tract infection. Facility documentation revealed Resident #1 had multiple prior falls in April. The Care Plan dated March 10, 2014 did not address the recent falls. The facility failed to adequately care plan for falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +WB154102,50M019,RCF,12/12/2015,Reported Perpetrator 2 (RP2) slapped Resident #1 on the hand when he/she resisted being pushed in his/her wheelchair. RP2's actions are considered physical abuse. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +DA116108,50M026,RCF,12/30/2010,"A Facility staff member reported overhearing another Facility staff member, Reported Perpetrator #2 (RP2) verbally mistreat a resident of the Facility. RP2 was known to be snippy and sarcastic to the residents. The Facility terminated RP2 following the incident of verbal mistreatment. The Facility did not keep records related to the Facility's investigation into the incident or report the suspected abuse to the Department.",2,0,,, +CO11077,50M026,RCF,6/14/2011,see condition folder. Action is based on preliminary survey findings from 6/14/2011.,3,0,,,Neglect +DA118135,50M026,RCF,10/3/2011,The facility failed to assess and evaluate safety risks for Resident #1's ability to cross a busy road.,2,0,,, +DA118233,50M026,RCF,8/23/2011,"RV was found motionless and not breathing in his/her bed. W2 noticed RV's condition and informed W3, who called 911 while checking RV's Code. EMT's were dispatched to the facility and arrived about 5 minutes after the call. They then carried RV to the hallway floor and attempted to revive RV. W1 also arrived to assist with efforts to revive RV. Efforts to revive RV did not succeed.",0,0,,, +DA120855,50M026,RCF,8/9/2012,Resident #2 is care planned to wear a smoking vest and be supervised when smoking. Resident #1_x001A_s care plan changed regarding his/her smoking from independent to supervised when he/she was found smoking in his/her room. Both residents use oxygen tanks to assist with breathing. Both residents consistently were found with burn holes in his/her clothes. The facility failed to assure that Resident #1 and Resident #2 were safe. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA132296A,50M026,RCF,1/26/2013,Reported Perpetrator 2 (RP2) opened Resident #1's mail without his/her permission. The facility failed to assure resident's rights. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA132356,50M026,RCF,1/24/2013,The facility failed to provide adequate peri care to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA132296B,50M026,RCF,1/26/2013,Witness 6 stated they gave Resident #1 his/her prescribed medications as Resident #1 was leaving the premises and assumed he/she would take them. The facility failed to administer the medications as ordered. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA133890,50M026,RCF,7/19/2013,"Resident #1's condition changed, due to medication and a disease process. Resident #1 had multiple falls and injuries and left the facility on several occasions. The facility failed to update Resident #1's service plan to reflect the change in condition or reflect interventions put into place to address him/her leaving the facility. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DA133757,50M026,RCF,7/7/2013,"The facility failed to monitor and intervene when Resident #1 experienced a change of condition. Resident #1 was admitted to the hospital and diagnosed with a stage IV decubitus ulcer. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +DA133829,50M026,RCF,7/4/2013,"As Reported Perpetrator 2 (RP2) moved Resident #1's wheelchair, Resident #1 fell to the floor. RP2 did not immediately assist him/her off the floor but instead told Resident #1 to get up on his/her own. Another staff person was able to assist with getting Resident #1 into the wheelchair. The facility failed to protect Resident #1's Resident Rights. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +DA135395,50M026,RCF,10/4/2013,Reported Perpetrator 2 did not speak with respect to Resident #1. The facility failed to ensure resident rights and is a violation of Oregon Administrative Rules.,2,,,, +DA135401,50M026,RCF,10/14/2013,"Resident #1 and Resident #2 had an altercation over a chair, with no reported injuries. Resident #1 had history of aggressive behavior. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,,, +DA134962,50M026,RCF,10/18/2013,"The facility failed to have appropriate interventions, safety measures, and reflective care plans for Resident #1 and Resident #2 regarding behaviors. Resident #1 and Resident #2 had a physical altercation. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +DA145806,50M026,RCF,1/19/2014,"Resident #1 fell in the shower and sustained a fracture to his/her arm. The facility failed to provide a non-slip floor surface in bathing areas to prevent falls and failed to take reasonable precaution to provide a safe and hygienic environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +DA145926B,50M026,RCF,1/17/2014,"The facility failed to provide a non-slip floor surface in bathing areas to prevent falls and failed to take reasonable precautions to provide a safe environment. Resident #1 suffered a fall with injuries. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +DA145997A,50M026,RCF,2/3/2014,"The facility failed to follow physician's orders regarding medication management of Resident #1's diabetes resulting in high blood sugar levels over a period of time. Facility staff did not have proper training to successfully administer medication for diabetes. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +DA145997B,50M026,RCF,2/3/2014,"The facility failed to maintain regular cleanliness in the showers, exposing residents to potential harm. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +DA147304A,50M026,RCF,6/5/2014,"Reported Perpetrator 2 (RP2) gave Resident #1 medication that was not ordered by his/her physician. Witness testimony and documentation revealed that Resident #1 was given extra medications to sedate, calm or put him/her to sleep. RP2 is found responsible for wrongful use of a chemical restraint, which constitutes abuse. The facility failed to take reasonable precautions to provide a safe environment and protect Resident #1 from RP2's actions. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,350,Substantiated,Substantiated,Restraints +DA147304B,50M026,RCF,6/5/2014,"Witness testimony and documentation revealed that Reported Perpetrator 2 (RP2) had slapped Resident #1's face and stomped on his/her foot on multiple occasions which caused pain. RP2 is found responsible for physical abuse. The facility failed to take reasonable precautions to provide a safe environment and protect Resident #1 from RP2's actions. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,,Substantiated,Substantiated,Physical Abuse +DA147304C,50M026,RCF,6/5/2014,"Reported Perpetrator 2 (RP2) wrongfully took money, other items, and accepted gifts from Resident #1. RP2 is found responsible for financial exploitation which constitutes abuse. The facility failed to take reasonable precautions to provide a safe environment and protect Resident #1 from RP2's actions. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",4,,Substantiated,Substantiated,Financial abuse +DA147304D,50M026,RCF,6/5/2014,"Reported Perpetrator 2 (RP2) conducted in inappropriate sexual contact with Resident #1. RP2 is found responsible for sexual abuse. The facility failed to take reasonable precautions to provide a safe environment and protect Resident #1 from RP2's actions. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,,Substantiated,Substantiated,Sexual abuse +DA147537,50M026,RCF,6/23/2014,"Residents #1, #2 and #3 reported experiencing emotional harm and loss of dignity due to actions of Reported Perpetrator 2 (RP2). RP2 is found responsible for verbal/emotional abuse. The facility failed to ensure residents were free from abuse which is considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +CO14225,50M026,RCF,10/28/2014,"The facility failed to provide effective administrative oversight regarding residents_x001A_ quality of care and services as evidenced by the re-licensure survey revisit #1 (#MXDN12) findings completed on October 28, 2014.",3,,,,Neglect +DA148887,50M026,RCF,10/3/2014,Resident #1 did not receive incontinence care as care planned. He/she was incontinent and soaked with urine. The failure is a violation of resident rights and is a violation of Oregon Administrative Rules.,2,,,, +DA149147,50M026,RCF,7/6/2014,"Reported Perpetrator 2 (RP2) admitted to stealing 5 narcotic pills from the medication room and was arrested. RP2's actions of theft are considered financial exploitation and constitute abuse. RP2 was re-hired by the facility after this incident. The facility failed to take reasonable precautions to provide a safe environment to protect residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Financial abuse +DA147288,50M026,RCF,6/2/2014,"Reported Perpetrator 2 (RP2) slapped Resident #1 in response to Resident #1 pinching RP2. RP2's actions are considered physical abuse. Resident #1 was known to pinch. The facility failed to ensure a safe environment and failed to implement interventions for staff to follow regarding Resident #1's behaviors. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Physical Abuse +DA152347,50M026,RCF,7/21/2015,"Resident #1 eloped from the facility on 7/22/15 sometime after 12:00am but wasn_x001A_t noticed missing until approximately 4:40am - 5:00am. His/her whereabouts were unknown until he/she was found over 30 hours later sitting in a stream. Resident #1 was transported to the hospital for dehydration, bruises and scratches. He/she had attempted to leave the facility several times on 7/21/15; however there were no progress notes regarding the attempts. Resident #1 had a history and risk of elopement; however there are no interventions in his/her care plan. The facility failed to monitor and care plan appropriately for Resident #1 to ensure a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA152401,50M026,RCF,6/15/2015,"The facility failed to adequately care plan related to Resident #1's falls and failed to monitor him/her as care planned. Resident #1 fell on 6/27/15, 7/10/15, and 7/17/15 with no injuries. The failures are a violation of resident rights and Oregon Administrative Rules.",2,,,, +OR0001033904,50M026,RCF,12/1/2015,,0,,,Substantiated, +DA153242,50M026,RCF,10/18/2015,"Resident #1 had a history of elopement. On 10/18/15, he/she eloped from the facility at shift change and was returned approximately 30 minutes later unharmed. The facility failed to ensure his/her care plan was followed to monitor. The failure is a violation of resident rights and violates Oregon Administrative Rules.",2,,,, +OR0001018402,50M026,RCF,10/20/2015,,0,,,Substantiated, +BC116544,50M037,RCF,3/15/2011,A resident of the Facility experienced a loss of his/her medication when a Facility staff member momentarily handed a family member of the resident the resident_x001A_s medication cards. The family member took two pills belonging to the resident. It had been Facility practice to give the resident_x001A_s medications to the family member to then administer to the resident. The family member ingested the resident_x001A_s medications while standing at the medication room still.,2,0,,,Financial abuse +BC133670,50M037,RCF,6/29/2013,Reported Perpetrator 2 (RP2) purposely sprayed Resident #1 in the face with hot water while assisting him/her in the shower and called Resident #2 a derogatory name. The facility failed to protect Residents #1 and #2 from verbal and emotional abuse. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for verbal and emotional abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +BC159992,50M037,RCF,1/14/2015,"Resident #1 is prescribed a medication patch that is to be changed daily. Reported Perpetrator 2 (RP2) failed to administer Resident #1's medication patch on January 14, 2015. There was no negative outcome to Resident #1. The facility failed to administer Resident #1's medication as prescribed. The failure is a violation of Oregon Administrative Rules.",2,,,, +HM118111,50M039,RCF,8/17/2011,"Resident #1 had a history of difficult behaviors and on August 17, 2011, she/he slapped RP2. RP2 responded by slapping Resident #1. The facility failed to provide a safe environment resulting in harm. RP2 was apportioned abuse.",2,0,Not Substantiated,Substantiated,Physical Abuse +HM118784,50M039,RCF,6/1/2011,Resident #1 reported RP2 inappropriately touched Resident #1 sexually while providing shower assistance. RP2 also asked Resident #1 to engage in sexual behavior while in a vehicle. Resident #2 reported RP2 was sexually inappropriate and refused to allow RP2 to shower her/him. Both Resident #1 and Resident #2 objected to RP2's sexaul advancements. The facility failed to ensure a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for sexual abuse.,3,0,Not Substantiated,Substantiated,Sexual abuse +HM129406,50M039,RCF,1/30/2012,"Resident #1 had an order for antibiotics filled on January 27, 2012. The facility picked up the medication on January 30, 2012. The facility failed to administer medication as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,0,,, +PT132888,50M039,RCF,3/8/2013,"Resident #1 was a fall risk with a history of falls and falling out of bed. He/she was care planned to have a mattress on the floor next to his/her bed. The mattress had been removed for cleaning. Resident #1 fell out of bed sustaining skin injuries. He/she was sent to the hospital as a precaution, no other injuries were found. The facility failed to follow Resident #1_x001A_s service plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HM133461,50M039,RCF,5/28/2013,"Residents #1 and #2 had an altercation, resulting in Resident #2 hitting Resident#1's arm. No injuries were reported. Resident #2 had been in previous altercations and was care planned for aggressive behavior. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +HM134912,50M039,RCF,10/19/2013,RP2 administered Resident #1 another resident's medication resulting in transportation to the hospital for observation with no remarkable change. The facility failed to ensure medications were administered as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO14005,50M039,RCF,11/15/2013,"The Facility failed to consistently evaluate and monitor residents' status or conduct an RN assessment for significant change of conditions. Resident #1 experienced pain from burns that required transporation to the hospital for treatment. Resident #2 experienced severe weight loss in one month and Resident #4 experienced wounds that worsenend. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,900,,,Neglect +HM147977,50M039,RCF,7/15/2014,"Resident #1 had a condition related memory impairment and was care planned for hourly checks due to a history of elopement. At approximately 9:00 PM, Resident #1 was discovered on her/his hands and knees on the side of a road several miles from the facility and was taken back. The facility failed to appropriately monitor Resident #1 resulting in the potential for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to facility closure on September 30, 2014.",3,,,,Neglect +HM148135,50M039,RCF,7/9/2014,Complainant reported Resident #1 was missing several narcotic patches when she/he moved out of the facility. Witness testimony and facility documentation revealed that the resident had the appropriate amount when she/he left.,,,,, +BC120615,50M048,RCF,7/24/2012,"Resident #1 had a known history of alcohol abuse and aggressive behavior when drinking. On or about July 24, 2012, Resident #1 returned to the facility from drinking and hit Resident #2 causing injury. The facility failed to appropriately monitor and intervene resulting in harm to Resident #2 and potential harm to all residents at the facility. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +HB151808,50M049,RCF,7/3/2015,RP2 slapped Resident #1 while providing care. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +BH105533,50M054,RCF,9/20/2010,The facility failed to provide a safe environment resulting in the loss of resident money after being charged for RP2's cell phone usage. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH116416,50M054,RCF,2/21/2011,"Resident #1 was not able to call for staff assistance due to the Facility's call system being broken. Staff was instructed to do thirty minute checks on all residents during this time, but this proved to be too much for staff and the checks did not get done as requested. Resident #1 spent a significant amount of time on his/her floor, approximately ten and a half hours.",2,0,,,Neglect +BH118126,50M054,RCF,8/24/2011,"Resident #1 was identified as dependent for mobility and required two person transfers for safety. The facility failed to ensure Resident #1_x001A_s service plan was followed resulting in a fractured femur. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH118537,50M054,RCF,11/30/2010,The facility failed to administer medication as ordered resulting on Resident #1 not receiving an ordered dose. The failure is a violation of OARs.,2,0,,, +BH128972A,50M054,RCF,1/4/2012,"Resident #1 reported missing narcotic medication from her/his room, but investigation was unable to determine who was responsible for theft. An unknown person was found responsible for financial abuse. The facility failed to provide a safe environment resulting in the loss of medication from Resident #1's room.",2,0,Not Substantiated,Substantiated,Financial abuse +BH128972B,50M054,RCF,1/4/2012,"In November 2011, Resident #1 was observed to be unable to properly administer medications to self and requested an order from the physician to have the facility dispense medications. Physician granted the request, however facility continued to allow Resident #1 to administer medications to self. The facility failed to provide a safe medication administration system resulting in the potential for harm to Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH129046A,50M054,RCF,1/21/2012,Resident #1 was discovered with a fractured ankle after complaining of pain for two days. Investigation discovered that RP2 was observed transferring the resident by her/himself when Resident #1 required a two person transfer. Two other staff indicated that the resident's foot was bumped during a transfer. It is unclear how the ankle came to be broken. The facility failed to ensure Resident #1's Service Plan was followed. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH129046B,50M054,RCF,1/21/2012,"Resident #1's ankle was observed to be swollen and turned in on January 21, 2012. Resident #1 continued to complain of pain and was agitated. Resident #1 was not sent in for x-rays until January 23, 2012 where it was discovered she/he had a fractured ankle. The facility failed to seek timely medical attention resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH129346,50M054,RCF,2/3/2012,The facility failed to coordinate services to ensure Resident #1's stiches were removed timely. The failure is a violation of Oregon Administrative Rules.,1,0,,, +BH129528,50M054,RCF,3/15/2012,"The facility failed to answer the call light in a timely manner after Resident #1 fell. Witness #3 found Resident #1 and had to get Kitchen staff to assist Resident #1. The facility did not evaluate the resident after the fall. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH118439,50M054,RCF,10/18/2011,RP2 confronted Resident #1 after hearing a private conversation she/he was having regarding RP2. The facility failed to ensure resident rights and is a violation of Oregon Administrative Rules.,2,0,,, +BH120472,50M054,RCF,6/20/2012,"Resident #1 reported narcotic medication missing from a locked drawer in the apartment. Observation of the locked area indicated that it was tampered with. RP2 was suspected, but investigation was unable to determine who took the narcotic medications. The facility failed to ensure a safe environment. An unknown person was held responsible for abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BH120707B,50M054,RCF,7/30/2012,Facility documention directed staff to notify family when 10 pills remain for one of Resident #1's vitamins. The facility waited until the medication ran out to order from the pharmacy. The facility failed to follow Resident #1's Medication Administration Record protocol resulting in missed doses of the resident's vitamins. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH129665,50M054,RCF,3/30/2012,Resident #1 has a chronic medical condition that requires he/she eat within half an hour of receiving his/her medication. Resident #1 receives his/her medication at 4:30 pm and is supposed to eat by 5:00 pm. Resident #1 often does not receive dinner until 5:30 or 5:45 pm. By this time Resident #1 is not feeling well. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH135319,50M054,RCF,12/5/2013,Reported Perpetrator #3 (RP3) did not follow Resident #1's care plan indicating a two-person transfer. Resident #1 suffered a skin tear as a result. RP3 was found responsible for neglect of care which constitutes abuse. The facility failed to ensure Resident #1's care plan was followed which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +BH135150,50M054,RCF,10/24/2013,"Resident's #1, #2, #3, #4, and #5 had money go missing from their rooms. Reported Perpetrator #2 was found responsible for theft of funds, which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC116679,50M055,RCF,3/14/2011,A resident of the Facility did not receive ordered doses of medication due to confusion related to how many individuals were involved in the resident's medication regimen. The resident was not reported to have experienced a negative outcome as a result and the Facility took steps to solve the issue.,2,0,,, +BC118331,50M055,RCF,10/23/2011,Resident #1 was given another resident's medication resulting in lower blood pressure. RP2 was required to work day shift after coming off of a double shift the day before. The facility failed to provide a safe medication administration system resulting in a negative outcome to Resident #1.,2,0,,,Neglect +BC120157A,50M055,RCF,5/29/2012,Resident #1 missed a dose of medication due to the facility not placing the order timely. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC120637,50M055,RCF,6/16/2012,"Resident #1_x001A_s medications were administered by the facility. On June 16, 2012, the facility ran out of his/her pain medication. Resident #1 had to be taken to the emergency room to get his/her medication. Resident #1 was in significant pain for over seventeen hours. The facility failed to provide a safe medication administration system resulting in Resident #1 going to the emergency room. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC120719,50M055,RCF,7/29/2012,"Resident #1 experienced pain during the night and pulled his/her emergency call bell for assistance. Facility staff failed to respond. Resident #1 then called 911. The facility failed to have a working call system resulting in pain and suffering. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC121726,50M055,RCF,11/27/2012,The facility did not have one of Resident #1_x001A_s medications available; the prescription had not been refilled. He/she had a physician_x001A_s appointment on the same day so was able to get it refilled and bring it back to the facility so he/she did not miss a dose. The facility has not had Resident #1_x001A_s medications available in the past. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121902,50M055,RCF,10/10/2012,Resident #1 had checks stolen from his/her checkbook. Three checks were cashed. The facility was notified by Resident #1_x001A_s family. An unknown individual was responsible for the loss of resident property. The facility failed to conduct an internal investigation or report the theft to APS. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC132173A,50M055,RCF,1/11/2013,Resident #1 was prescribed a variable dose medication. Resident #1 was not given the correct dose. He/she did not feel well. The facility failed to follow Resident #1_x001A_s physician order. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC133791,50M055,RCF,6/27/2013,"An unknown person took money from Resident #1's apartment. It was reported Resident #1 always kept his/her apartment door locked. Facility staff had keys to Resident #1's apartment. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BC133595,50M055,RCF,4/28/2013,"Physician's orders were faxed to the facility on two occasions, directing staff to allow Resident #1 to self-medicate. Reported Perpetrator 2 (RP2) ignored the orders both times. In addition, RP2 stated he/she chose not to perform a nursing assessment on Resident #1. The facility failed to follow physician's orders and perform an adequate assessment. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC133788,50M055,RCF,6/26/2013,Multiple allegations of theft were reported by facility residents. Resident #1 was missing $300. Resident #2 was missing $600.00. Resident #3 was missing $80. An unknown individual was responsible for the loss of resident's money. The facility failed to provide a safe environment and investigate allegations of theft. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BC134341,50M055,RCF,9/1/2013,"Residents #1 and #2 had money stolen from locked containers in their respective apartments. The facility had other thefts and purchased surveillance cameras for security. However, the cameras did not work because of the construction of the walls and ceilings; they ordered more expensive cameras. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BC134474,50M055,RCF,9/5/2013,Resident #1 and Resident #2 reported money missing from their rooms. An unknown individual was found responsible for the loss of Resident #1 and Resident #2_x001A_s money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BC134558B,50M055,RCF,7/29/2013,"Resident #1 had several un-witnessed falls while at the facility sustaining bruising. No amendments were made to his/her service plan. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC134636,50M055,RCF,10/4/2013,Resident #1 reported a $500 money order missing from his/her room. It was found that Reported Perpetrator 2 (RP2) had endorsed the money order. RP2 repaid Resident #1. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of resident rights.,2,300,Not Substantiated,Substantiated, +BC134375B,50M055,RCF,9/5/2013,Resident #1 reported $60.00 and small vintage ceramic figures missing from his/her room. An unknown individual was responsible for the loss of Resident #1's property. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BC146486,50M055,RCF,3/24/2014,Resident #1 has a history of falls and continues to be a fall risk. Resident #1 fell on the bus while on an outing sustaining bruising on the back of his/her knees. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC146878,50M055,RCF,4/4/2014,Resident #1 had a history or pocketing and hiding medications. Resident #1's physician ordered that medications were to be crushed. His/her service plan did not reflect his/her fall on 4/4/14. The facility failed to administer Resident #1's medication as ordered and failed to update his/her service plan to reflect his/her physician's orders and his/her fall. The failures are a violation of Oregon Administrative Rules.,2,,,, +BC146866,50M055,RCF,4/5/2014,The facility failed to provide a safe medication administration system resulting in errors regarding Resident #1's medication administration. Resident #1's medication was not administered as ordered by his/her physician. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC147106,50M055,RCF,5/7/2014,Resident #1's physician changed the dosage of a medication and he/she was not administered the correct dosage. The facility failed to administer Resident #1's medication according to his/her physician's orders. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC146940,50M055,RCF,4/21/2014,The facility failed to administer Resident #1's medication according to physician's orders. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC148026,50M055,RCF,6/8/2014,"Resident #1 experienced a fall and sustained bruising to his/her upper arm and a bump and abrasion to his/her head. Resident #1 had morning blood sugar levels below 70 on nine occasions between 5/22/14 and 6/8/14. The facility failed to notify Resident #1's physician regarding his/her low blood sugar levels. Resident #1 was transported to the hospital by a family member. The facility failed to follow Resident #1's physician's orders regarding blood sugar levels. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC150523,50M055,RCF,2/26/2015,"The facility failed to administer several of Resident #1_x001A_s medications for several days. Resident #1 experienced increased pain and edema in his/her legs as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",3,300,,,Neglect +BC151100,50M055,RCF,4/26/2015,"Resident #1 had medications go missing from his/her room. The medications were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC151411,50M055,RCF,5/22/2015,The facility failed to adequately treat Resident #1 with dignity and respect. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC154116,50M055,RCF,12/25/2015,The facility failed adequately provide care services for Resident #1. The facility did not have enough staff to answer Resident #1's call light in a timely manner. Facility staff also failed to look for Resident #1 after he/she left with paramedics. These failures are a violation of Oregon Administrative Rules.,2,,,, +MS105577,50M056,RCF,10/23/2010,A resident experienced a loss of his/her personal property when it was taken from his/her room within the Facility. The resident reported the incident to the Facility and the resident was reimbursed for his/her loss.,2,0,,, +MS117043,50M056,RCF,5/21/2011,A resident of the Facility experienced a loss of his/her personal resources when his/her bag was left in the dining room following a meal. The resident's bag was later discovered hanging from the inside of a door knob in a laundry room. Upon inspection the resident discovered that money from his/her bag was missing.,2,0,,,Financial abuse +MS117657,50M056,RCF,8/9/2011,"Resident #1 was identified as a fall risk. The facility failed to assure Resident #1 was safe resulting in the potential for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS117752A,50M056,RCF,8/18/2011,"Resident #1 was found cold and soiled and indicated she/he had not been changed in several hours. The facility failed to follow Resident #1's Service Plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS121929,50M056,RCF,12/20/2012,Resident #1_x001A_s service plan states he/she is a fall risk. He/she had two recent falls without the service plan being updated regarding falls. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS133893,50M056,RCF,7/24/2013,Resident #1 called for assistance to the restroom at 9:25 a.m. He/she did not receive assistance until 10:45 a.m. This caused Resident #1 to be upset and uncomfortable. The facility failed to timely respond to Resident #1_x001A_s call for assistance. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS134358,50M056,RCF,9/8/2013,Resident #1 grabbed Resident #2_x001A_s arm in an aggressive manner. Resident #1 has thrown things at another resident and was verbally aggressive toward other residents. Resident #1 has also threatened harm to other residents before this incident. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS121669,50M056,RCF,11/21/2012,Resident #1 reported pain medication missing from his/her room while he/she was in the hospital. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MS146623,50M056,RCF,4/7/2014,Resident #1 was a fall risk and had several falls since the first of the year. One fall resulted in Resident #1 sustaining a broken wrist. There were no amendments to his/her service plan. The facility failed to update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS134671,50M056,RCF,10/9/2013,"Resident #1 was involved in an altercation with Resident #2 causing skin injury to Resident #2. Resident #1 has had prior incidents with Resident #2 and other residents. The facility failed to implement interventions to address Resident #1's aggressive behaviors that had been demonstrated prior to this incident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS150046,50M056,RCF,1/25/2015,Reported Perpetrator #2 (RP2) attempted to transfer Resident #1 with a gait belt and Resident #1 did not want a gait belt used. Resident #1 became combative and RP2 continued to attempt to transfer Resident #1 with the gait belt. Resident #1 developed bruising as a result. RP2 is responsible for neglect of care which constitutes abuse. The facility failed to protect Resident #1 from rough treatment.,2,,Not Substantiated,Substantiated,Neglect +MS149472,50M056,RCF,12/4/2014,"The facility failed to adequately monitor Resident #1 and provide physical assist while escorting him/her to the dining room. Resident #1 fell and fractured his/her clavicle and orbital bone. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS151325,50M056,RCF,5/19/2015,"The facility failed to adequately assess and intervene in relation to Resident #1_x001A_s frequent falls. Resident #1 has fallen several times and he/she fell again resulting in a cervical fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS152895,50M056,RCF,9/23/2015,"Residents #1 #2 had money go missing and Resident #3 had medications go missing. The money and medication were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +MS152365,50M056,RCF,8/6/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA117141,50M065,RCF,5/16/2011,"The facility failed to provide a safe environment resulting in Resident #1 successfully eloping from the facility causing minor harm to self. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,0,,,Neglect +DA129661,50M065,RCF,3/22/2012,"Staff noticed increased bruising on residents including Resident #1 but failed to conduct an investigation in a timely manner. Staff also reported observing RP2 improperly transferring Resident #1 which may have caused bruising. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 is no longer employed by the facility.",2,0,,,Neglect +DA129744,50M065,RCF,4/8/2012,"Resident #1 had a history of sleep apnea and was admitted to the facility on or about March 8, 2012. Resident #1's initial evaluation dated March 8, 2012 documented that the service plan called for delegation to staff for the use of CPAP devise. Collected documentation revealed the CPAP was not started on Resident #1 until March 22, 2012. The facility failed to administer medical treatment as ordered and failed to follow up in a timely manner resulting in the potential for harm to Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +DA129971,50M065,RCF,4/30/2012,Resident #1 was admitted to the facility with known exit seeking behavior. Resident #1 continued to exhibit exit seeking behavior while at the facility and managed to elope by using a chair left outside to get over the fence. Resident #1 was found unharmed approximately two miles from the facility before the facility was aware the resident had left. The facility failed to appropirately monitor Resident #1 resulting in successful elopement. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA120898B,50M065,RCF,6/29/2012,"A complaint of potential verbal abuse was reported to RP3. RP3 failed to report the suspected abuse, failed to appropriately investigate and retaliated against the complainant. The failures are violations of Oregon Administrative Rules and are a potential for harm to all residents.",2,0,,, +DA121243A,50M065,RCF,9/11/2012,It was reported that the facility failed to allow Resident #1_x001A_s family to stay with him/her at the time of their passing. Reported Perpetrator 2 (RP2) informed the family that they could not stay the night with Resident #1. A compromise was finally reached to let Resident #1_x001A_s family stay until he/she passed. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA134613,50M065,RCF,8/29/2013,"In August 2013 Resident #1 left the facility to visit with family members. Resident #1 refused to return to the facility after this visit. Facility staff visited Resident #1 at his/her family members home to try an convince Resident #1 to return to the facility. While at the home facility staff picked up Resident #1 while he/she was in his/her chair and carried him/her outside. By carrying Resident #1 outside the facility failed to treat Resident #1 with dignity and respect, and failed to respect Resident #1's choice in treatment options. This failure is a violation of Oregon Administrative Rules.",2,,,, +DA134752,50M065,RCF,9/20/2013,"Resident #1 and Resident #2 engaged in a physical altercation that resulted in Resident #1 being transported to the hospital for treatment. Both residents had histories of aggressive/agitated behaviors and their respective care plans did not adequately address the residents' behaviors. The facility failed to appropriately care plan and monitor resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,250,,,Neglect +DA151371,50M065,RCF,5/25/2015,Resident #1 experienced an increase in falls. The facility failed to update Resident #1's care plan after making changes to her/his care to address the falls. The failure is a violation of Oregon Administrative Rules.,2,,,, +DA152700,50M065,RCF,8/31/2015,"The facility failed to ensure a safe environment resulting in a physical altercation with Resident #1 and Resident #3. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DA154019,50M065,RCF,12/16/2015,"On or about December 16, 2015 RV1, RV2 and RV3 were involved in an altercation. RV1 and RV3 had a physical altercation prior to 12/16/15. RV2's care plan stated that he/she is territiorial and that RV2 should not be alone in an activity with RV1. RV1, RV2 and RV3 were alone in the facility living room when the incident occoured. The facility's failure to provide a safe environment is a violation of resident rights, is condidered neglect of care and constitutes abuse.",2,,,,Neglect +DA148632,50M065,RCF,8/27/2014,"On or about August 23, 2014 RV1 became angry and aggressive, taking a fire extinguisher and breaking out a window in the facility. On August 24, 2014 RV1 hit RV2 with his/her cane and RV2 was transported to the hospital to check for injuries. On August 27, 2014 there was an altercation between RV1 and RV3 where bruising was evident the following day. The facility's failure to provide a safe and secure environment is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH118702,50M081,RCF,9/23/2011,It was reported that Resident #1 and Resident #2 are not being given adequate supervision. Upon investigation it was determined that the facility failed to develop an adequate plan to monitor Resident #1 and #2. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH133055,50M081,RCF,4/24/2013,Non-narcotic medications were found in Resident #1_x001A_s medication bottle mixed together with the narcotic medications. An unknown individual was found responsible for the loss of Resident #1_x001A_s medication. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC116431,50M086,RCF,2/20/2011,"When a resident of the Facility was found by staff to have experienced an episode of incontinence a Facility staff member, Reported Perpetrator #2 (RP2) began to verbally ridicule the resident and cursed at the resident. RP2 did not follow the resident's service plan with respect to toileting and incontinence issues. The actions of RP2 resulted in the abuse of a Facility resident.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +BC117419,50M086,RCF,7/4/2011,Reported Perpetrator 2 and Resident #1 exchanged escalating and sarcasm comments when Resident #1 continued to complain about food items.,2,0,,, +BC129581,50M086,RCF,3/18/2012,Reported Perpetrator 2 (RP2) and Witness #1 were providing care for Resident #1. Resident #1 requested a kiss from RP2. RP2 gave Resident #1 a _x001A_peck_x001A_ on the lips. The facility failed to assure Resident #1_x001A_s resident rights. The failure is a violation of Oregon Administrative Rules.,1,0,,, +BC118481,50M086,RCF,10/20/2011,"Reported Perpetrator 2 (RP2) was verbally inappropriate with Resident #1 and he/she was visibly upset after the incidents. The facility did not do an internal investigation to rule out abuse or report incidents of October 20, 2011 and October 29, 2011. RP2 was found responsible for abuse. The facility failed to assure Residents #1_x001A_s rights and conduct an investigation to rule out abuse. The failure is a violation of resident rights and constitutes verbal abuse.",2,0,Substantiated,Substantiated,Verbal/Mental abuse +BC132310,50M086,RCF,1/26/2013,Resident #1 punched Resident #2 in the face after Resident #2 refused to give him/her a cigarette. Resident #2 sustained a red mark. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC133490,50M086,RCF,4/20/2013,"Resident #1 hit Resident #3 while smoking unsupervised. Both Resident #1 and Resident #3 are service planned to be supervised while smoking. Resident #1 hit Resident #2 while waiting in a medication administration line. The facility failed to follow the service plans for Resident #1 and Resident #3. The facility also failed to address Resident #1_x001A_s behaviors. The failures resulted in Resident #2 being sent to the hospital and Resident #3 sustaining a bloody nose and bruises. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC147117,50M086,RCF,3/21/2014,Resident #1 fell in the hallway when he/she collided with another resident. He/she complained of pain. Resident #1 was not taken to the hospital for reported pain after his/her fall. A physician's appointment was not scheduled until seven days after the fall. The facility failed to obtain timely medical treatment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC159881,50M086,RCF,1/4/2015,The facility failed to administer Resident #1's medications according to his/her physician's orders. Resident #1 did not suffer any negative outcome. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC152746,50M086,RCF,9/6/2015,"Resident #1 was not administered his/her pain medication from September 6, 2015 to September 8, 2015. Resident #1 experienced pain due to not receiving his/her medication. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC152990,50M086,RCF,9/29/2015,Resident #1 appeared with a large bruise above his/her elbow. There were no witnesses to the incident that caused the bruising. Resident #1 said someone grabbed his/her arm causing the injury. An unknown individual was determined to be responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BC153437,50M086,RCF,11/3/2015,Resident #1 was administered twenty-five pills instead of one pill. Resident #1 was transported to the hospital and treated for an overdose. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB154013,50M088,RCF,12/21/2015,"RV1 has a history of hitting various residents in the facility. On or about February 10, 2016 RV1 approached RV3 and struck him/her on the left ear. The facility's failure to provide a safe environment and failure to provide appropriate support and intervention for behaviors are violations of the Oregon Administrative Rules.",2,,,, +BC116413B,50M092,RCF,2/13/2011,"A resident of the Facility failed to receive appropriate oral care. Facility staff indicated the resident was resistive to oral care, however the resident's service plan did not address the resident's oral care needs and methods for reproaching the resident to ensure that his/her oral care needs were being met.",2,0,,, +BC129481A,50M092,RCF,3/1/2012,Resident #1 had recently returned from a hospital stay and needed to use a wheelchair. A bed sheet was being used to secure Resident #1 in his/her chair without a physician_x001A_s order. The facility failed to properly use a restraint. The failure is a violation of Oregon Administrative Rule.,2,0,,, +BC129481B,50M092,RCF,3/1/2012,"Resident #1, #2 and #3 had falls and had to remain on the floor until another staff person arrived to help assist them up. The facility failed to provide appropriate care for Resident #1, #2 and #3. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO12105,50M092,RCF,9/7/2012,"The findings of the Residential Care Facility Re-licensure Survey completed on April 4, 2012, and three revisit surveys completed on May 16, 2012; July 25, 2012 and September 17, 2012, determined that the Facility continues to be out of substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility_x001A_s noncompliance placed residents at risk for harm. The failures are a violation of Oregon Administrative Rules.",2,0,,, +CO14131,50M092,RCF,6/3/2014,"The Facility failed to provide effective administration oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed June 3, 2014(DOKL11).",3,,,,Neglect +BH146004,50M094,RCF,2/4/2014,"Resident #1 had a history of physcial altercations with other residents. On or about February 4, 2014, Resident #1 engaged in a physical altercation with Resident #2 resulting in shoulder pain. The facility failed to ensure a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH146357,50M094,RCF,3/5/2014,"Resident #1 had a diagnosis related to vision impairment and history of misplacing wallet. On or about March 5, 2014, Resident #1 reported missing her/his wallet and checkbook. Resident #1's room was searched and the checkbook was found but not the wallet. Resident #1 suspected another resident of taking the wallet, however it is unclear if it was wallet was taken or misplaced. During the course of the investigation it was discovered that a lockable storage space was not available to the resident at the time of the incident and one was later installed. The failure is a violation of Oregon Administrative Rules.",2,,,, +BH133900,50M094,RCF,5/31/2013,Resident #1 left the facility and became lost for 12 hours. The facility was unaware of the resident's absence until her/his return. The facility failed to ensure a safe environment resulting in the potential for harm. This notification was processed at a later date due to the timeframe between the investigation and when it was submitted for processing.,2,,,, +BH153935A,50M094,RCF,6/10/2014,The facility failed to ensure Resident #1's medication change was updated on the Medication Administration Record and failed to order the medication resulting in the resident not receiving the medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC120580,50M096,RCF,7/6/2012,Resident #1 was given medications that belonged to another resident. The only reported side effect was that Resident #1 was extremely sleepy. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121011,50M096,RCF,9/1/2012,"Resident #1 received his/her medications in a cup with his/her name on it. He/she set the medication cup on the dining room table to get something to drink. Upon returning, he/she discovered that Resident #2 had taken his/her medications. Resident #2_x001A_s physician was called and he/she was monitored. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC133724,50M096,RCF,7/5/2013,Resident #1 was administered another resident_x001A_s medications. The error was discovered immediately and Resident #1 was monitored during the night. He/she was sent to the hospital the next day and was returned to the facility within hours with no treatment. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC152412,50M096,RCF,6/9/2015,"Narcotic medications were tampered with and reported missing for Resident #1, Resident #2, and Resident #3. Reported Perpetrator 2 (RP2) is responsible for the theft of narcotic medications which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +CO12064,50M110,RCF,3/2/2012,"The facility failed to monitor, evaluate and refer to the facility RN and conduct an RN assessment for Resident #4 who experienced a significant change of condition. Resident #4 experienced a severe weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC134499,50M110,RCF,9/6/2013,"The facility failed to provide a safe medication administration system to ensure resident specific medication administration. Resident #1 received an incorrect medication and was transported to the hospital for treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +CO14091,50M110,RCF,4/24/2014,"The facility failed to ensure Resident #6 was monitored, and failed to ensure reasonable precautions were exercised against a condition that could threaten the health, safety or welfare of Resident #6 who demonstrated unsafe smoking practices. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC150370,50M110,RCF,2/3/2015,The facility failed to adequately administer a safe medication administration system. Resident #1 missed a dose of two different types of medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC150848,50M110,RCF,4/1/2015,The facility failed to adequately assess and intervene when resident #2 began exhibiting more sexual behaviors. Resident #1 wandered into Resident #2's room and the two were stopped right before the two engaged in intercourse. Resident #1 does not have capacity to consent to sexual relations. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC151166,50M110,RCF,5/1/2015,The facility failed to adequately monitor Resident #2 and provide a safe environment to Resident #1. Resident #2 had a history of inappropriate behaviors toward Resident #1. Resident #1's door lock was also not working properly and Resident #2 was able to gain access to Resident #1's room with Resident #2's room key. Resident #2 did not have any physical contact with Resident #2 and left when Resident #1 told him/her to. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC152426,50M110,RCF,8/9/2015,"The facility failed to adequately plan care in relation to Resident #2's aggressive behavior towards other residents. Resident #2 was able to hit and spit on several residents, and failed to implement interventions to address Resident #2's behavior. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +NB135047A,50M124,RCF,11/10/2013,The facility failed to provide a safe medication administration system resulting in several residents not receiving prescribed medications. The failures are a violation of Oregon Administrative Rules.,2,,,, +CO15161,50M124,RCF,8/13/2015,"The facility failed to provide effective administrative oversight regarding residents_x001A_ quality of care and services as evidenced by the re-licensure survey findings completed on September 11, 2015 (YOT411).",3,,,,Neglect +OR0000986802,50M124,RCF,8/4/2015,,2,,,Substantiated, +ES105460,50M132,RCF,10/4/2010,"A resident of the Facility did not receive an ordered medication when the medication was not available due to being depleted. Facility staff did not reorder the resident's medication timely, resulting in the resident not receiving the ordered medication. The resident did not experience harm as a result of the missed medication.",1,0,,, +CO12086,50M132,RCF,5/9/2012,"The facility failed to ensure compliance with the health care rules to evaluate, develop appropriate interventions, monitor and provide an RN assessment for Resident 2 who experienced worsening pressure ulcer.",1,300,,,Neglect +ES121641,50M132,RCF,11/15/2012,Resident #1_x001A_s CBG was to be taken at 4:00 a.m. RP2 was responsible for that task. Resident #1 was found unresponsive with a CBG of 29 at about 7:40 a.m. Resident #1 was transported to the hospital. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Neglect +ES133280,50M132,RCF,5/20/2013,"The facility failed to care plan appropriately and implement interventions regarding Resident #2_x001A_s behaviors. Resident #1 was affected by Resident #2_x001A_s behaviors. Resident #2 lacked a diagnosis of dementia at the time of his/her admission to the facility and at the time the facility moved him/her into memory care. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse and constitute abuse.",4,2500,,,Sexual abuse +CO13115,50M132,RCF,9/19/2013,"The preliminary findings of the Residential Care Facility Survey conducted October 1-4, 2013; determined that the Facility was not in substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility's noncompliance placed residents at harm and risk for serious harm. The failures are a violation of resident rights, are considered neglect and constitute abuse. Findings include but are not limited to: + + + +The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the survey citations. Please refer to the survey for specific details.",3,,,, +ES134421A,50M132,RCF,9/12/2013,"Resident #1 had a history of being inappropriate with staff. Resident #1 was found holding hands with Resident #2. Resident #1 touched Resident #2's breast under his/her blouse. The facility failed to appropriately service plan Resident #1 for inappropriate sexual behaviors. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants an enhanced civil penalty; however, due to the fact that the facility is on a current condition (RCFCD13-007) a civil penalty will not be issued.",3,,,,Neglect +ES134310,50M132,RCF,8/26/2013,Resident #1 reported $45.00 missing. An unknown individual was responsible for the loss of Resident #1_x001A_s money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,,Financial abuse +ES134641,50M132,RCF,10/7/2013,"Resident #1 was a fall risk and had several falls with no amendments made to his/her service plan. Resident #1 also lost a significant amount of weight. The facility failed to adequately update Resident #1's service plan to address fall interventions and weight loss. The facility failed to assess, care plan and appropriately monitor after significant changes of condition. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,, +ES134868,50M132,RCF,10/22/2013,Resident #1 was prescribed pain medication to be administered twice per day. Resident #1 was not administered one dose of his/her medication. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES134663,50M132,RCF,10/8/2013,Resident #1 required assistance with eating and staff were to assist him/her. Resident #1 was found with food and no caregivers around to assist him/her. The facility failed to provide Resident #1 with the services that he/she needs. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES134294B,50M132,RCF,8/28/2013,Resident #1_x001A_s treatment device needed to be cleaned after each use. The facility could not find the order for cleaning the device. Staff were not recording on the Medical Administration Record (MAR) when the device was cleaned. The facility failed to have a tracking system in place to assure the treatment device was cleaned and maintained properly. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES135078,50M132,RCF,11/13/2013,Resident #1 reported money missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +CO14047,50M132,RCF,12/20/2013,The facility failed to follow licensing condition #RCFDC13-007 restricting admissions. The license condition was in effect on 10/17/2013 requiring that the facility not admit any new residents into their facility until further notice. Resident #14 was admitted to the facility and began receiving services on 11/1/13. The failure is a violation of license condition #RCFCD13-007 and Oregon Administrative Rules.,3,300,,, +ES135039,50M132,RCF,11/9/2013,"Resident #1 eloped from the facility by exiting a door that was supposed to be locked and secured. The door had not been latching properly and the facility was aware of this. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES135213,50M132,RCF,11/1/2013,Resident #1 had an order for two prescription nutritional supplements to be taken one time per day. The order changed the beginning of November to take two times per day. The change was not implemented until twenty-five days later. Resident #1 reported feeling tired before the change was implemented. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES134822A,50M132,RCF,10/2/2013,Resident #1 reported $80.00 missing from his/her room. Resident #1 was not provided with a lockable storage space. An unknown individual was found responsible for the theft of Resident #1's money which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES134920,50M132,RCF,8/1/2013,Resident #1 reported cash missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES134822B,50M132,RCF,10/2/2013,"Resident #1 was known to be at risk for weight loss as it was known that she/he did not care for the food that was served by the facility. Resident #1 lost approximately eight pounds between 9/12/13 and 10/2/13. Resident #1 was also a known fall risk. The facility failed to appropriately care plan relating to weight loss and falls. The facility also failed to follow Resident #1's physician's order regarding administration of a pain medication resulting in Resident #1 experiencing pain. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility is on a current condition (RCFCD13-007) a civil penalty will not be issued.",3,,,,Neglect +ES134778,50M132,RCF,10/17/2013,Resident #1 was prescribed pain medication to be administered every day at 8:00 a.m. Resident #1 was not administered his/her medication at 8:00 a.m. on 10/17/13. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES134869,50M132,RCF,10/27/2013,Resident #1_x001A_s toenails were long and were not being cut. The facility failed to care plan regarding cutting Resident #1_x001A_s toenails or notify his/her physician that Resident #1 was refusing care. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES134541,50M132,RCF,9/4/2013,Resident #1 reported $60 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES146361,50M132,RCF,3/4/2014,Resident #1 reported missing $35 from his/her room. An unknown individual was determined to be responsible for the loss of Resident #1's money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES135538,50M132,RCF,12/31/2013,The facility received a one time dosage change for Resident #1. The facility did not administer the medication as ordered. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES135331,50M132,RCF,12/6/2013,"There was no charting to substantiate how many times Resident #1 was offered fluids, undergarments changed or refusal of showers. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES135411,50M132,RCF,12/16/2013,Resident #1 was found in bed without his/her tab alarm being activated. His/her pants were also pulled down around his/her ankles. The facility failed to follow Resident #1_x001A_s service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES135375,50M132,RCF,12/8/2013,Resident #1 was not given his/her 8:00 a.m. medication on 12/8/13. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES145864,50M132,RCF,1/14/2014,Resident #1 had doctor's orders for his/her medication to be held for ten days prior to surgery. The facility did not hold Resident #1's medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES135041,50M132,RCF,10/29/2013,"Resident #1 fell nine times between 8/1/13 and 11/12/13 with no interventions being added to his/her service plan. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition at the time of the incident (condition #RCFCD13-007) a civil penalty will not be issued.",3,,,,Neglect +ES145862,50M132,RCF,1/16/2014,"Resident #1 was administered a medication that had been discontinued for two days. At the time, Resident #1 did not complain of pain or discomfort and a nursing assessment was done with no negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES146113,50M132,RCF,2/7/2014,Resident #1's family was to be contacted as an intervention prior to administering a sedative medication. The facility administered the medication without contacting Resident #1's family. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES146312,50M132,RCF,3/6/2014,Resident #1 was found in the same cloths as the day before and in a saturated incontinent brief. Resident #1 was refusing care and being combative with staff. The facility failed to appropriately train staff regarding refusal of care. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES147159B,50M132,RCF,5/17/2014,Resident #1's care plan states that he/she is to have oxygen at all times. Resident #1 did not have his/her oxygen for approximately two and a half hours. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148470,50M132,RCF,9/5/2014,"Resident #1, Resident #2 and Resident #3 were involved in an altercation. + +Resident #1 and Resident #2 did not sustain injury. Resident #2 sustained a skin tear. Resident #1 has a history of resident to resident altercations. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES147864,50M132,RCF,7/17/2014,Resident #1 care plan states he/she is to be transferred using a gait belt. Resident #1 was transferred without using a gait belt and fell. No injuries were sustained. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148351,50M132,RCF,8/28/2014,The facility is responsible for managing all of Resident #1's medications. Resident #1 was prescribed a medication by his/her physician. Resident #1's medication was not ordered in a timely manner causing Resident #1 discomfort. The facility failed to order Resident #1s medication in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148322,50M132,RCF,8/21/2014,Resident #1_x001A_s care plan states his/her call bell is to be within reach when he/she is in his/her room. Resident #1 was left in his/her chair with the call bell left out of his/her reach. He/she tried to reach it and fell. Resident #1 sustained an abrasion and some slight bruising. The facility failed to follow the care plan for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES147524,50M132,RCF,6/20/2014,"Resident #1 reported his/her wallet missing from his/her room. The wallet contained a bank card and $110.00. An unknown individual was determined to be responsible for the theft which constitutes financial exploitation. The facility failed to provide a safe environment. + +The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES147226,50M132,RCF,5/21/2014,Resident #1 reported $70.00 missing from his/her room. An unknown individual was determined to be responsible for the theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES149274,50M132,RCF,10/28/2014,"Resident #1's leg wounds were not appropriately assessed. When Home Health assessed Resident #1, he/she was sent to the hospital. The facility failed to provide oversight and monitoring of Resident #1's change of condition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +ES148418,50M132,RCF,8/30/2014,"Resident #1 was a fall risk but did not have a history of falls. His/her care plan stated that staff would transfer Resident #1 with a gait belt and stabilize him/her when standing. Resident #1 fell sustaining injury and was transported to the hospital. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility had a change in the ownership a civil penalty will not be issued.",3,,,,Neglect +ES148916C,50M132,RCF,10/9/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Both residents had been involved in previous altercations with other residents. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148486,50M132,RCF,9/7/2014,Resident #2 was involved in an altercation with Resident #1. The facility failed to address Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148375,50M132,RCF,8/27/2014,"Resident #1 returned from an outing with family. Witness #2 stated he/she let staff know of Resident #1's return. Resident #1 was found on the floor of the dining room. Resident #1 was transported to the hospital and diagnosed with a fractured right arm. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility had a change in ownership a civil penalty will not be issued.",3,,,,Neglect +ES149566,50M132,RCF,12/8/2014,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 has a history of altercations with other residents. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES150416,50M132,RCF,2/18/2015,Resident #1 was admitted to the hospital for an unrelated issue. It was discovered that Resident #1 had skin breakdown. The facility had no documentation that Resident #1 had any skin issues. The facility failed to provide appropriate skin care for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES149011,50M132,RCF,10/18/2014,Resident #1 hit Resident #2 on the hand. Resident #1 had a history of altercations. No injuries were sustained. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES149135,50M132,RCF,11/2/2014,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 had a history of altercations with other residents. No injuries were sustained. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES148147,50M132,RCF,8/11/2014,"Resident #1 was care planned as a two person transfer. RP2 transferred Resident #1 by her/himself and the resident complained of back pain the following day. Investigative details revealed RP2 had come in to work to cover for another staff person two hours after her/his normal shift and felt rushed to complete tasks. Investigation determined that the facility failed to ensure enough staff to provide adequate care to residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES151004,50M132,RCF,4/20/2015,"Resident #1 had a diagnosis of diabeties that required insulin injections and also had a prn pain medication order. RP2 did not allow Resident #1 to take her/his diabetic medication with her/him while out of the facility resulting in a missed dose and is a potential for harm. The facility also failed to ensure Resident #1 received her/his pain medication in a timely manner resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES150721,50M132,RCF,1/1/2015,"Complainant reported the facility was not administering Resident #1's blood pressure medication as ordered. Witness testimony and facility documentation revealed more medication pills in stock then there should be, however staff and resident state that medications are administered as ordered. The facility did not keep track of the amount of medications that they had prior to Witness #3 bringing in two separate orders of the same medication. Investigation concluded that the facility failed to ensure a safe medication administration system resulting in the potential for harm.",2,,,, +ES150872,50M132,RCF,3/29/2015,"Resident #1 had a history of combative behavior and an interim care plan was put in place to address behavior when providing care. On or about March 27, 2015, RP2 and RP3 provided incontinence care resulting in bruising to Resident #1. RP2 and RP3 did not follow interventions as care planned, however investigative details revealed that the facility failed to adequately train staff regarding care and combative behaviors. The failure is a violation of resident rights, is considered neglect of care resulting in physical harm. A change of ownership occurred on April 1, 2015.",2,,,,Neglect +ES152571,50M132,RCF,8/24/2015,"Resident #1 and Resident #2 were on blood thinning medication that required regular testing. The facility failed to ensure timely testing as ordered by the physician. Resident #1's lab work completed five days the after physician_x001A_s order directed, showed significantly high INR levels. Resident #1 was transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES152863,50M132,RCF,8/24/2015,"Staff reported to Reported Perpetrator 2 (RP2) their concerns regarding a change of condition for Resident #1. RP2 did not do daily checks and was not on frequent checks. Resident #1 was not sent to the hospital for two weeks. The care plan did not reflect Resident #1's current needs. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to assess for a change of condition and intervene. The facility also failed to obtain timely medical treatment for Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,,Not Substantiated,Substantiated,Neglect +GP116090,50M133,RCF,1/3/2011,Resident #1 was inappropriately touched and exposed sexually by Reported Perpetrator 2.,3,0,Not Substantiated,Substantiated,Sexual abuse +NB121053,50M138,RCF,9/11/2012,"Resident #1 reported that a $20 bill, a package of pens and 1 sheet of stickers were missing from his/her room. An unknown individual is responsible for Resident #1's loss of property. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +NB121398,50M138,RCF,10/6/2012,"Reported Perpetrator 2 (RP2) did not provide care as required to Resident #1 and Resident #4, and did not provide appropriate medication administration to Resident #2 and Resident #3. RP2's failures resulted in poor continuity of care, missed and/or incorrect medications, and a wound not properly bandaged. RP2 is found responsible for neglect, constituting abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +NB134266,50M138,RCF,8/28/2013,"The facility failed to care plan appropriately and failed to provide services for Resident #1's known behaviors placing him/her and others at risk of harm. Law enforcement was contacted due to the facilities failures to meet Resident #1's care needs, and he/she was restrained and forcefully removed from the facility resulting in bruising, abrasions and swelling. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NB151051,50M138,RCF,4/22/2015,Reported Perpetrator (RP2) was mean and yelled at residents. RP2's behavior upset residents to the point where they wouldn't request treatments or medications because they were afraid of negative outcome. Residents #1 through #7 and staff were affected by RP2's verbal abuse and actions. RP2's actions are considered verbal/mental abuse. The facility failed to provide a safe environment which violates Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Verbal/Mental abuse +NB151817,50M138,RCF,7/2/2015,"Between 6/16/15 and 6/30/15, money, personal belongings, and a wallet were reported missing from residents and one staff person. An unknown person is responsible for theft, which constitutes financial exploitation. The facility failed to take reasonable precautions to provide a safe environment and be free from theft. The failures is a violation of resident rights and violated Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +OT134619,50M142,RCF,3/27/2013,"Resident #1 had several pieces of jewelry and other items go missing in October 2013. These items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +OT146050A,50M142,RCF,1/15/2014,Resident #1 had indicated several times he/she did not want RP2 to enter his/her room for housekeeping services. In or around January of 2014 RP2 entered Resident #1's apartment for housekeeping and caused Resident #1 to feel threatened. The facility failed to assure Resident #1's rights to refuse service. This is a violation of Oregon Administrative Rules.,2,,,, +OT153583,50M142,RCF,11/4/2015,"Reported Perpetrator #2 (RP2) left Resident #1 unassisted in his/her bathroom while helping another resident. Resident #1 then attempted to transfer to the toilet themselves, fell, and sustained an injury. RP2 is responsible for neglect of care which constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +OT154008,50M142,RCF,12/4/2015,"Resident #1 had credit cards go missing. The credit cards were taken by an Reported Perpetrator #2 and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +PT118075,50M144,RCF,9/1/2011,"Resident #1's service plan requires a body pillow next to her/him when in bed. On at least one occasion, the body pillow was not next to Resident #1. The facility failed to follow Resident #1's service plan resulting in the potential for harm.",2,0,,, +PT132566,50M144,RCF,2/2/2013,"Reported Perpetrator 2 (RP2) was witnessed forcing Resident #1_x001A_s pills into his/her mouth, forcing Resident #1 to drink water to swallow the pills and then covering Resident #1_x001A_s mouth with RP2_x001A_s hand. RP2 had also raised his/her voice to yell at Resident #1. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +PT146696,50M144,RCF,3/23/2014,"Resident #2 got agitated and slapped Resident #1 leaving redness on his/her face. Resident #2 had a history of aggression. The facility failed to monitor and implement interventions regarding Resident #2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +PT151380A,50M144,RCF,1/16/2015,"Resident #1 developed a decubitus ulcer. The facility failed to monitor and provide care to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +PT151380B,50M144,RCF,1/16/2015,Reported Perpetrator 2 (RP2) developed an intimate relationship with Resident #1. The facility was aware and failed to report to the local APS office and failed to provide a safe environment to protect Resident #1 from inappropriate sexual contact. The failure is a violation of resident rights and constitutes sexual abuse.,2,2500,Substantiated,Substantiated,Sexual abuse +GP118713,50M154,RCF,12/16/2011,RP2 was observed yelling and being verbally inappropriate with several residents. Facility staff did not notify administration immediately after incidents occurred. The facility failed to protect residents from RP2's verbal outburst. The failure is a violation of resident rights and constitutes verbal abuse. Both the facility and RP2 were found responsible for abuse.,3,300,Substantiated,Substantiated,Verbal/Mental abuse +GP120251,50M154,RCF,6/10/2012,"On June 10, 2012 Resident #1 wandered outside the building and fell with minor injury. Resident #1 had a history of wandering behavior beleiveing she/he needed to go to work. On two of these occasions, Resident #1 was found outside. The facility failed to update Resident #1's care plan to address this issue. The facility failed to address a resident's behavior resulting in minor injury with the potential for moderate harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +GP148297,50M154,RCF,8/28/2014,"Resident #1 has a physican's order for a wheelchair seatbelt. On or about August 28, 2014, Resident #1 experienced an injury fall out of her/his wheelchair. Witness testimony revealed Resident #1's seatbelt and was not functioning at the time of the incident. Investigation concluded the facility failed to maintain Resident #1's care equipment resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP148678,50M154,RCF,9/21/2014,"Resident #1 had a history of combative and confrontational behavior that negatively affected other residents. On August 21, 2014, Resident #1 engaged in a verbal altercation that turned physical towards Resident #2 and Witness #4. Resident #1's care plan failed to provide clear direction to staff on how to address Resident #1's behavior towards other residents. The facility failed to adequately care plan Resident #1's behavior resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP147520B,50M154,RCF,6/25/2014,Complainant reported RP3 was verbally inappropriate when speaking to residents. Investigative findings revealed that RP3 had a loud voice and had used inappropriate language with residents. The facility failed to ensure residents were treated with dignity and respect and is a violation of Oregon Administrative Rules.,2,,,, +GP151738,50M154,RCF,6/26/2015,The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC151471,50M157,RCF,5/30/2015,The facility to protect Resident #1 from loss of dignity when Reported Perpetrator #2 would not help Resident #1 with toileting. Resident #1 was asked to wait instead of receiving toileting assistance. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC153138,50M157,RCF,9/7/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DL145675B,50M169,RCF,1/4/2014,The facility had a house rule that residents were to have televisions off and be in bed by 10:00 PM. RP2 requested Resident #1 hang up the phone multiple times after hearing/observing Resident #1 talking on the phone after 10:00 PM. RP2 used a raised voice when telling Resident #1 to hang up the phone. Facility failed to ensure resident rights and is a violation of Oregon Administrative Rules.,2,,,, +DL150666,50M169,RCF,10/1/2014,The facility failed to ensure Resident #1's medication was administered as ordered resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +ES121316,50M172,RCF,10/10/2012,Resident #1 was resistive to care. He/she is care planned to stop and reapproach later. The care plan also states to try another caregiver if re-approaching doesn_x001A_t work. The facility failed to follow resident #1_x001A_s care plan resulting in Resident #1 sustaining bruising to his/her right arm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES132250,50M172,RCF,1/25/2013,"Resident #1 requires care during the night; while getting Resident #1 changed an incident occurred. Reported Perpetrator 2 (RP2) and Witness #1 have conflicting descriptions of the physical contact RP2 made to Resident #1 and weather or not Resident #1 had bitten RP2. The facility failed to properly care plan for Resident #1's behaviors and provide staff with training and interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,, +ES133816,50M172,RCF,7/10/2013,Resident #1 was admitted to the facility the end of April. He/she was not added to the shower log that the facility staff uses to track which residents are to be showered each day and when. Resident #1 was not added to the shower log until mid July. There was no evidence that Resident #1 was showered as care planned except for verbal assurances. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES133862,50M172,RCF,6/18/2013,"Reported Perpetrator 2 (RP2) put Resident #1 in a ""bear hug"" by going behind him/her and putting RP2's arms around him/her and picking Resident #1 off the ground. RP2 dropped Resident #1 in a controlled fall. Resident #1 sustained red marks on his/her upper arms. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +ES134664B,50M172,RCF,10/7/2013,"Resident #1 has a history of aggressive behavior towards other residents, and is known to get more aggressive after his/her significant other visits. Resident #1 struck Resident #3 without provication as Resident #3 passed him/her in the dining area. Resident #1's significant other had visited prior to this. The facility failed to adequately assess and intervene related to Resident #1's aggression. This failure is considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES145934,50M172,RCF,1/22/2014,"Resident #1 and Resident #2 were involved in a previous altercation. Resident #2 had a history of wandering the halls and going into other resident rooms. He/she was also a fall risk. Resident #1 pushed Resident #2 to the ground, resulting in Resident #2 being transported to the hospital where he/she died as a result of complications during surgery. The facility failed to address Resident #1's behavior and monitor Resident #2 when wandering the halls at night. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,450,,,Neglect +ES152139,50M172,RCF,7/18/2015,"On or about July 18, 2015 Reported Victim #1 (RV1) and Reported Victim #2 (RV2) were involved in an altercation in the hallway at the facility. Witness #1 heard yelling from the kitchen, looked down the hallway and observed RV1 grabbing RV2 around the neck. Witness #1 stated that he/she was the first person to arrive to the altercation and that there were no other staff around. RV1 had a history of altercations with visitors, staff and other residents. RV1 had been placed on alert charting numerous times due to behaviors and altercations. The facility failed to provide a safe and secure environment for RV1 and RV2.",2,,,, +ES151882A,50M172,RCF,7/6/2015,Reported Perpetrator 2 (RP2) was witnessed handling Resident #1 roughly and jerking Resident #1's arm. RP2 was found responsible for physical abuse. The facility failed to report the incident to APS. The facility also failed to provide a safe environment. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +ES151882B,50M172,RCF,7/6/2015,Reported Perpetrator 2 (RP2) was witnessed responding to Resident #1 with hostile and inappropriate comments that include inappropriate language. RP2 was found responsible for verbal abuse. The facility failed to report the incident to APS. The facility also failed to provide a safe environment. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +ES153902,50M172,RCF,12/9/2015,"Resident #1 slapped Resident #2's hand. Resident #1 had a history of altercations with staff, visitors and other residents. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV105486,50M174,RCF,9/22/2010,A resident of the Facility was discovered to have suffered injury due to what was described as not wearing leg protectors during a transfer. The resident was also observed to have a bed rail attached to his/her bed without a proper safety assessment. The Facility removed the bed rail.,2,0,,,Neglect +MV132737,50M174,RCF,3/22/2013,"Resident #1 was administered the incorrect amount of insulin. Reported Perpetrator 2 (RP2) administered 30 units instead of 3 units. RP2 was not delegated for insulin administration. Resident #1 became unresponsive and was transported to the hospital. RP2 was found responsible for abuse. The facility failed to provide a safe medication administration system and assure that RP2 had appropriate training. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +MV134303,50M174,RCF,8/28/2013,"Resident #1 and Resident #2 were involved in two altercations. The second altercation resulted in Resident #1 being discovered on the floor. Resident #1 was transported to the hospital. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,, +MV135056,50M174,RCF,11/11/2013,Resident #1 reported coins missing from a jar in his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MV129868,50M174,RCF,3/28/2012,"Resident #1 was given the incorrect dose of a medication. Resident #1 was transported to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted; however, one will not be issued due to the extended period of time between the incident date and processing by the Department.",2,,,,Neglect +MV135108,50M174,RCF,9/25/2013,Resident #1 was care planned to have a bed alarm and a fall mat in use due to the risk of falls. Resident #1 was found on the floor. The bed alarm was not attached and the fall mat was under the bed. Resident #1 sustained a small abrasion to his/her forehead The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV147198,50M174,RCF,5/26/2014,Resident #1 and Resident #2 had a history of alterations with other residents. Resident #1 got very close to Resident #2 and yelled for help. This startled Resident #2 who pushed Resident #1. Resident #1 fell and bumped his/her head. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV148645,50M174,RCF,9/19/2014,"Resident #2 pushed Resident #1 causing him/her to fall. Resident #1 was transported to the hospital for further evaluation due to an abrasion on his/her head. Both residents have been involved in previous altercations with each other. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV151274,50M174,RCF,5/12/2015,"Resident #1 had a history of aggressive behavior. On or about May 12, 2015, staff observed Resident #1 intentionally tripped Resident #2 as she/he was walking by resulting in a fall. The facility failed to ensure a safe environment, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO13002,50M201,RCF,12/3/2012,"The facility failed to ensure a fall with fracture was investigated in order to rule out the possibility of neglect or report to the local SPD or AAA offices. Residents #1 and #2 failed to be referred for a significant change of condition to the RN. Resident #1 experienced two falls which resulted in fractures and had significant weight loss. Resident #2 had a physician_x001A_s order that was not transcribed onto the MAR and the facility did not monitor the resident_x001A_s bowel status. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,, +BA164172,50M204,RCF,2/9/2013,"Between 2/9/13 and 4/8/13, Reported Perpetrator 2 (RP2) financially exploited Resident #1, Resident #2 and Resident #3 totaling approximately $5,755.52. RP2's actions are considered abuse. The facility failed to protect residents from financial exploitation to ensure a safe environment. The failure is a violation of Oregon Administrative Rules.",4,,Not Substantiated,Substantiated,Financial abuse +GB116255,50M208,RCF,1/29/2010,"A Facility staff member, Reported Perpetrator #2, was known by his/her peers to act like he/she did not care for Resident #1 as a person. While providing care to Resident #1, RP2 was witnessed to have _x001A_whacked_x001A_ Resident #1 on his/her mouth. The incident occurred as a result of Resident #1 saying _x001A_ow_x001A_ repeatedly.",2,0,Substantiated,Substantiated,Physical Abuse +GB116115,50M208,RCF,1/6/2011,"The facility failed to assure timely medical treatment and monitoring when Resident #1, Resident #2 and Resident #3 experienced a change of condition resulting in transportation to the hospital. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,900,,,Neglect +GB133593,50M208,RCF,6/23/2013,"Resident #1 had Witness #9 place two, one hundred bills in his/her pants pocket for him/her. Resident #1's clothes were taken to the laundry the same day. The next morning when Resident #1 went to get his/her money, it was not in the pants pocket. All of the caregivers stated they had no knowledge of what happened to the money and it was never recovered. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. An unknown person is responsible for taking Resident #'1s money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +GB146881A,50M208,RCF,4/23/2014,The facility failed to protect Resident #1 from inappropriate comments made by facility staff. This failure is a violation of Oregon Administrative Rules.,2,,,, +GB149423,50M208,RCF,11/30/2014,"Residents #1 through # had medication taken from the facility medication room. Resident #1 also had money taken out of his/her account with the debit card he/she let Reported Perpetrator #2 (RP2) use to buy items for Resident #1 at a store. RP2 is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's through Resident #3's property from theft. This failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +GB150538,50M208,RCF,3/12/2015,"The facility failed to answer Resident #1's call light in a timely manner. Resident #1 was left in his/her bed for over 30 minutes after activating his/her call light, and on another occasion was left on the toilet for over 40 minutes. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +GB151294A,50M208,RCF,5/15/2015,The facility failed to provide homelike environment in relation to inappropriate comments made by Reported Perpetrator #2. This failure is a violation of Oregon Administrative Rules.,2,,,, +RB105797A,50M209,RCF,12/5/2010,The facility failed to provide a safe medication administration system resulting in two residents not receiving their medications as ordered. Resident #1 was administered three times the prescribed dosage of narcotic medication outside of the medication's parameters. Resident #2 was administered twice the prescribed narcotic pain medication as ordered. Residents' physicians were not notified and their records failed to document the incident. The wrongdoing is a failure of Oregon Administrative Rules and created a potential for harm.,2,300,,, +RB105797B,50M209,RCF,12/5/2010,"The facility failed to appropriately transfer residents as directed on their care plans resulting in bruising to Resident #3 and Resident #4. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB116072B,50M209,RCF,8/1/2010,"The facility failed to provide a safe medication administration system resulting in the potential for harm to all residents. Collected information revealed that the facility put new measures in place and conducted all staff training related to their medication administration system. Facility history showed multiple substantiated allegations related to their medication system, however based on their changes, a sanction was not issued.",2,0,,, +RB116031,50M209,RCF,12/30/2010,"RP2 replaced Resident #1's medication patch twenty-four hours in advance. There was no harm as a result of the medication error. The facility failed to administer medication as ordered. Collected information revealed that the facility put new measures in place and conducted all staff training related to their medication administration system. Facility history showed multiple substantiated allegations related to their medication system, however based on their changes, a sanction was not issued.",2,0,,, +RB116033,50M209,RCF,12/29/2010,"A 30 pack of narcotic medication was taken from the medication room. Witness testimony revealed that the facility had a combination lock with a spare key next to the medication room. The combination was suppose to periodically change for safety reasons, but did not. The facility failed to provide a safe medication administration system resulting in the loss of a resident's medication. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +RB116085,50M209,RCF,1/3/2011,"The facility failed to administer medication as ordered. There was no harm as a result of the error. The failure is a violation of Oregon Administrative Rules. Collected information revealed that the facility put new measures in place and conducted all staff training related to their medication administration system. Facility history showed multiple substantiated allegations related to their medication system, however based on their changes, a sanction was not issued.",2,0,,, +RB116138,50M209,RCF,1/8/2011,"Resident #1 experienced increased confusion and behaviors with a history of leaving the facility. Resident #1 was found, on at least two occasions, walking next to a busy interstate highway. The facility failed to appropriately care plan for Resident #1 resulting in the potential for serious harm. The facility_x001A_s failure posed a risk of serious harm to the resident, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB116169,50M209,RCF,1/3/2011,"The facility failed to obtain a physician's order prior to administering a medication and the facility failed to reorder a resident's medication in a timely manner. There was no negative outcome as a result of the errors. Collected information revealed that the facility put new measures in place and conducted all staff training related to their medication administration system. Facility history showed multiple substantiated allegations related to their medication system, however based on their changes, a sanction was not issued.",2,0,,, +RB120535,50M209,RCF,7/1/2012,"Resident #1 had a history of aggressive behavior. Care plan did not address how staff were to respond to Resident #1's negative behavior, however staff aware that the resident responded well if talked in a calm manner. On or about July 1, 2012, RP2 failed to approach in calm manner resulting in Resident #1 reacting negatively. The facility failed to provide staff direction on Resident #1's care plan for dealing with behaviors. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RB121752,50M209,RCF,11/15/2012,"Resident #1 had physician's orders to treat pain. On November 3, 2012, the MAR (Medication Administration Record) revealed that Resident #1 was administered an over the counter pain medication because the facility was out of narcotic pain medication. Further review of the MAR dated November 19, 2012, did not correlate with the corresponding narcotic book that Resident #1 had been administered a dose of narcotic medication for pain. The facility failed to ensure a safe medication administration system resulting in Resident #1 not receiving a narcotic pain medication as ordered. Facilty records did not indicate that the failure resulted in negative outcome. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RB121567,50M209,RCF,11/8/2012,"Resident #1 was admitted with regularly scheduled narcotic pain medication management to be provided by the facility. On November 5, 2012, Resident #1's narcotic pain medication was unavailable resulting in the resident experiencing pain. Witness testimony and facility documentation revealed that approximately 52 narcotic pain medications were unaccounted for. There was no documentation tracking Resident #1's narcotic medication. The facility failed to provide a safe medication administration system resulting in unnecessary pain and loss of narcotic pain medication. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse.",3,300,,,Financial abuse +RB121966,50M209,RCF,12/19/2012,"The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving her/his pain medication and experiencing pain for two days. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +RB132359,50M209,RCF,2/4/2013,"Resident #1 required and was care planned for transfer assistance with toileting. On two known occasions, staff failed to answer the call light in a timely manner resulting in bowl incontinence and loss of dignity. Witness testimony revealed that staff changes were been adjusted. The facility failed to ensure Resident #1's care plan was being followed and failed to have adequate staff to meet residents' needs. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +RB132448,50M209,RCF,1/19/2013,"Resident #1 was observed with a large bruise on her/his chest and care planned for 1 person transfer assist or 2 person when weak. Witness testimony and facility documentation revealed W3 attempted a one person transfer of Resident #1 unsuccessfuly and had to re-transfer back to wheelchair from arm of chair. Facility determined that the bruise was a result of the transfer. The facility failed to provide clear staff directions on how to determine when Resident #1 was ""weak"" and therefore required a two person transfer.",2,0,,,Neglect +RB121967,50M209,RCF,12/20/2012,"Resident #1 experienced a change of condition and the physician requested an appointment the same week. Resident #1 was sent to the hospital twice on December 4, 2012 and ultimately did not return to the facility. The facility documented an appointment was made two weeks after the original request and was unable to show reason for delay. The facility failed to ensure timely doctor appointment per physician request. There is not enough information to determine if the facility's failure contributed to Resident #1's outcome. The failure is a violation of Oregon Administrative Rules",2,0,,, +RB132440,50M209,RCF,2/12/2013,RP2 forcefully held down Resident #1 and yelled at her/him. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for physical abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +RB132595,50M209,RCF,3/2/2013,"Resident #1 was a known fall risk and care planned for full assist with transfers. Facility documents revealed Resident #1 had a history of trying to get out of bed alone and staff were directed to remind the resident to use the call light. The facility failed to adequately care plan and monitor Resident #1 for falls resulting in an injury fall that required transportation to the hospital for treatment of a fractured pelvis. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB132438A,50M209,RCF,2/13/2013,"The facility failed to have pain medication available for Resident #1 for approximately four days. He/she had been receiving his/her PRN narcotic pain medication almost daily according to documentation prior to these four days. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +RS132901,50M209,RCF,4/8/2013,"Resident #1 has a condition related to memory loss and requires cuing with eating. The facility failed to assist Resident #1 with eating on the morning of April 8, 2013. Resident #1's spouse found Resident #1 in her/his room unattended to while she/he was out. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB132912,50M209,RCF,4/5/2013,The facility failed to provide resident rights to Resident #1 resulting in the loss of dignity. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB133016A,50M209,RCF,2/3/2013,The facility failed to have Resident #1's medication available to administer per physician_x001A_s orders. Resident #1 missed one dose of his/her medication. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB133832,50M209,RCF,7/15/2013,"Resident #2 has a history of aggressive behavior. Witness testimony and facility documentation revealed Resident #2 exhibited multiple aggressive behaviors towards residents. On or about July 15, 2013, Resident #2 engaged in a physical altercation with Resident #1 resulting in harm. The facility failed to appropriately care plan and monitor behaviors. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +RB134215,50M209,RCF,8/15/2013,"The facility failed to follow physician's orders, failed to have an accurate medication administration record and failed to timely respond to address Resident #1's pain. The failure is a violation of resident rights, is considered neglect of care resulting in unrelieved pain and constitutes abuse.",2,,,,Neglect +RB135194,50M209,RCF,11/15/2013,"Resident #1 and Resident #2 utilize wheelchairs. On or about November 13, 2013, residents were being evacuated due to a fire alarm. Facility staff failed to fully assist two residents with wheelchairs down a ramp resulting in injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB146538,50M209,RCF,3/26/2014,RP2 grabbed Resident #1 in an attempt to remove from the laundry room resulting in a large skin tear. Witness #3 intervened and redirected Resident #1 from RP2. RP2 was found substantiated for physical abuse. The facility to ensure a safe environment and is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +RB146863A,50M209,RCF,4/14/2014,Resident #2 was given another resident's medication. Resident #1's Medication Administration Record failed to accurately document missed doses of a particular medication that had not come in. There were no negative outcomes for either resident. The failures are violations of Oregon Administrative Rules.,2,,,, +RB146863C,50M209,RCF,4/14/2014,"Resident #3 fell and experienced a skin tear after RP2 inappropriately attempted to transport using a walker. Witness testimony revealed RP2 did not receive proper training. The facility failed to ensure a safe environment resulting in harm to Resident #3. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB147037,50M209,RCF,5/7/2014,"Resident #1 required physician ordered thickened liquids. Resident #1 was observed to choke after drinking liquid. Witness testimony and facility documentation revealed that kitchen staff were directed to add the liquid and forgot. Other care staff sign off that it has been added. The facility failed to provide a safe medication administration resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB146997,50M209,RCF,4/15/2014,"Complainant reported concerns regarding eating assistance to residents that require it. Witness testimony and facility documentation revealed the facility failed to follow residents' service plans relating to eating assistance. The failure is a violation of resident rights, is considered neglect of care a constitutes abuse. This report has been combined with license Condition RCFCD14-011.",2,,,,Neglect +CO14142,50M209,RCF,7/9/2014,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the re-licensure survey (#5XLJ11) findings completed on July 9, 2014 and the Residential Care Complaint Report #s RB146997 & RB147037. A Condition was imposed effective July 31, 2014. Please see corresponding Condition for specific details.",3,,,,Neglect +RB147534B,50M209,RCF,6/16/2014,"During the course of an investigation it was discovered that Resident #1's and Resident #2's care plan did not accurately reflect their current needs. Resident #1's care plan did not address her/his refusal to wear oxygen. Resident #2 care plan inaccurately identified she/he was a total assist for mobility when witness testimony revealed she/he was able to self-ambulate using a wheelchair. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,, +RB148250,50M209,RCF,8/15/2014,"Resident #1 required reminders and standby assist with all areas of personal hygiene. Resident #1 was discovered with long, curled toenails. Facility staff were unaware of Resident #1's unkempt toenails that required outside medical attention. The facility failed to provide appropriate care to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB159832,50M209,RCF,12/25/2014,"Resident #1 was transported to the hospital two days after continued complaints of pain and was treated for a fractured arm. The facility failed to seek timely medical treatment after Resident #1 experienced increased pain from a fall with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RS150853,50M209,RCF,4/1/2015,"The facility failed to ensure Resident #1's care plan was reflective of her/his needs and failed to follow the specialized care plan regarding resident's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS153156,50M209,RCF,10/12/2015,"The facility failed to ensure adequate nail care for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +OR0001015800,50M209,RCF,10/15/2015,,1,,Not Substantiated,Substantiated, +OR0001015802,50M209,RCF,10/15/2015,,1,,Not Substantiated,Substantiated, +BH121843C,50M218,RCF,11/27/2012,"Resident #1 reported to administration that he/she wanted no contact with RP2 and that RP2 no longer administer his/her medications. The facility failed to question why Resident #1 wanted no contact with RP2 and Resident #1 stated his/her medical condition worsened because of the distress of interacting with RP2.The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH121843B,50M218,RCF,11/27/2012,Reported Perpetrator 3 (RP3) was an employee of the facility and provided care and medication management to Resident #1. Phone records indicated that RP3 was having an intimate relationship with Resident #1. RP3 was found responsible for sexual abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Sexual abuse +BH147762,50M218,RCF,7/10/2014,Resident #1 was administered another resident's medication. Resident #1 did not experience any negative effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BR121563,50M220,RCF,6/14/2012,"The facility failed to adequately evaluate and care plan for Resident #1's needs and increased needs. Resident #1 did not receive the care necessary to maintain his/her health, wellbeing and safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BR146322,50M220,RCF,10/21/2014,Resident #1 did not receive his/her ordered medication. The facility failed to provide a safe medication administration system to ensure medications are administered as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BR148722,50M220,RCF,10/21/2014,The facility implemented an intervention by placing an alarm across the doorway to Resident #1's doorway to his/her apartment to alert caregivers and also placed a pressure alarm under his/her mattress. The facility failed to obtain physician's orders. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +BR152951,50M220,RCF,9/18/2015,"Resident #1 was care planned requiring extensive assistance to ensure adequate nutrition and that he/she cannot have an unplanned weight loss of 5% in 30 days. Resident #1 suffered a severe weight loss. The facility failed to ensure his/her care plan was followed, failed to intervene when he/she experienced a significant change of condition; and failed to ensure a Registered Nurse assessment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +BR153092,50M220,RCF,9/18/2015,"Resident #1 was care planned with instructions for weight monitoring and extensive meal assistance. Resident #1 suffered an unreasonable weight loss. The facility failed to ensure his/her care plan was followed, failed to intervene when he/she experienced a significant change of condition, and failed to ensure a Registered Nurse assessment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BR153191,50M220,RCF,8/17/2015,"Resident #2 had known physical and verbal aggression and was care planned requiring constant supervision for safety. Resident #2 was in Resident #1_x001A_s room and he/she hit Resident #1 who then fell and injured his/her head. He/she was transported to the hospital for treatment. The facility failed to monitor and ensure Resident #2_x001A_s care plan was followed to ensure resident safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BR153205,50M220,RCF,9/16/2015,"The facility failed to properly plan care regarding Resident #1's known attempts to transfer on his/her own. Resident #1 had fallen and suffered an abrasion to his/her left shin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BR153256,50M220,RCF,5/22/2015,The facility failed to have a safe medication administration system regarding Resident #1's blood sugar medication. The failures is a violation of resident rights and Oregon Administrative Rules.,2,,,, +BR153425,50M220,RCF,9/17/2015,"Resident #1's service plan states he/she was incontinent of urine and bowel; needed assistance to manage all phases of bladder care; staff to change his/her incontinence product when needed; and has a history of UTI's. On 9/26/15, Resident #1 was found in the same soiled brief approximately 24 hours later. The facility failed to ensure his/her service plan was followed and failed to ensure services were being provided. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BR153549,50M220,RCF,10/26/2015,"The facility failed to implement and care plan interventions regarding resident behaviors, and failed to adequately monitor. The failure resulting in an altercation with Resident #1 and Resident #2 and continued behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BR153541,50M220,RCF,9/16/2015,"The facility failed to ensure Resident #1's specific diet and meals were provided and failed to care plan appropriately for his/her dietary needs. Resident #1 lost weight. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BR153547B,50M220,RCF,10/29/2015,Resident #1 had dietary needs and restrictions. The facility failed to ensure palatable meals were available and care plan for his/her dietary needs. The failures are a violation of resident rights and violate Oregon Administrative Rules.,2,,,, +BR153540,50M220,RCF,9/18/2015,"The facility failed to ensure Resident #1's care plan and actual care was followed regarding incontinence. Resident #1 was left in soiled incontinence brief for extended periods of time and his/her wound integrity deteriorated. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BR153542,50M220,RCF,9/18/2015,The facility failed to provide a safe medication administration system regarding Resident #1's medication administration. The failure is a violation of Oregon Administrative Rules.,2,,,, +BR153539,50M220,RCF,9/18/2015,"The facility failed to provide care, follow care plan, and monitor Resident #1 regarding his/her daily needs including physical assistance and prompting to eat. Documentation indicated undesirable weight loss. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse. + + + +Note: This incident warrants a civil penalty; however the facility is under a current licensed condition.",3,,,,Neglect +BR153546,50M220,RCF,10/28/2015,"The facility failed to ensure Resident #1's and Resident #2_x001A_s care plan and actual care was followed regarding managing all phases of bowel and bladder care. Resident #1 and Resident #2 was left in soiled incontinence brief for extended periods of time. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +Note: This incident warrants a civil penalty due to recent related history of incontinence care; however the facility is under a current licensed condition.",2,,,,Neglect +BR154028,50M220,RCF,11/19/2015,"Amongst the facility changes in staff and routine, residents were not treated with dignity and respect. The facility failed to ensure resident dignity and respect for a safe and homelike environment. The failures is a violation of Oregon Administrative Rules.",2,,,, +BR153548,50M220,RCF,10/30/2015,The facility failed to ensure Resident #1's care plan was followed for housekeeping and toileting needs. There were soiled areas in his/her room and his/her soiled clothing was on the floor. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +BR153779,50M220,RCF,11/4/2015,"The facility failed to monitor and adequately care plan related to Resident #1's falls. He/she suffered injuries from falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +DA105388,50M225,RCF,9/24/2010,Resident #1's MARs (medication administration record) was not accurate and up to date revealing at least seven narcotic medication doses unaccounted for. RP2 consumed a narcotic medication belonging to a resident. The facility failed to provide a safe medication administration system resulting in the potential for harm to all residents.,2,0,,, +DA116961,50M225,RCF,3/6/2011,The facility failed to ensure appropriate staffing levels to meet the scheduled and unscheduled needs of all residents resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +DA129962,50M225,RCF,4/25/2012,"The facility failed to timely intervene after Resident #1 complained of pain resulting in several hours of unecessary pain and suffering. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,0,,,Neglect +CO14211,50M225,RCF,9/17/2014,"The facility failed to provide effective administrative oversight and ensure reasonable precautions were exercised to ensure residents' quality of care and services based on the deficiencies found. The facility also failed to ensure appropriate monitoring, RN assessment and interventions for residents who experienced significant and short term changes of conditions. Resident #1 continued to elope and Resident #2 experienced severe weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +DA147279,50M225,RCF,5/13/2014,The facility failed to ensure Resident #1's care plan was followed and is a violation of Oregon Administrative Rules.,2,,,, +DA147423,50M225,RCF,5/17/2014,"Resident #1 required assistance with transfers and care planned for sit to stand transfers. The facility failed to adequately train RP2 on appropriate transfer techniques resulting in bruising from improper transfer. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DA150318,50M225,RCF,1/18/2015,Resident #1 had a diagnosis related to cognition and could not safely leave the facility unattended. The facility failed to adequately care plan and monitor Resident #1 resulting in successfully elopement through her/his window twice. The resident was returned unharmed. The failures are violations of Oregon Administrative Rules.,2,,,, +DA147794,50M225,RCF,7/1/2014,"Staff observed liquid narcotic medication missing from Resident #1 and Resident #2's supply and an investigation was initiated. Neither resident were negatively affected by the incident. Witness #3 was suspected, however investigation was unable to determine who took the narcotics. The facility failed to ensure a safe environment resulting in the potential for harm. An unknown person was found responsible for theft of narcotics, is considered financial exploitation and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation and processing by the Department.",2,,Not Substantiated,Substantiated,Financial abuse +DA164428,50M225,RCF,1/16/2016,"On or about January 16, 2016, RV1 fell out of his/her bed resulting in bruising to his/her right eye and cheek. RV1's care plan stated that he/she was to wear a tab alarm at all times. Facility interviews and documentation indicates that RV1 was not wearing his/her tab alarm as required. The facility's failure to follow RV1's careplan is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO11043,50M227,RCF,3/2/2011,"The facility failed to ensure Resident #1_x001A_s Service Plan was reflective of current needs and failed to evaluate, provide appropriate interventions and consistently monitor Resident #1 who had a change in condition. The facility also failed to ensure an RN assessment was conducted after Resident #1 and #4 experienced significant changes in conditions. Resident #1 lost a severe amount of weight and Resident #4 experienced unaddressed pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +DA116287,50M227,RCF,2/5/2011,"A resident of the Facility was witnessed on multiple occasions to not be receiving necessary oral care. The resident's teeth were observed to be encrusted with food and other debris. The resident was to receive assistance from staff for his/her oral care needs, per the resident's service plan.",2,0,,, +DA118695,50M227,RCF,11/30/2011,"Resident #1 is a know fall risk and required assistance with ambulation and transfers. On or about November 30, 2011, Resident #1 was observed on the floor covered in feces. The one care staff on duty called to request assistance and was directed to cover Resident #1 up until day shift staff came on duty. Resident #1 was left on the floor covered in feces for several hours before being assisted and cleaned. Resident #1 was not evaluated for injuries. The facility failed to provide appropriate staffing to meet Resident #1_x001A_s needs; failed to evaluate for injuries and failed to treat with dignity and respect. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA121609,50M227,RCF,10/31/2012,Resident #1 was given the wrong medication. The only reported side effect was that Resident #1 was very sleepy. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA159853,50M227,RCF,12/21/2014,"Resident #1 was identified as an exit seeker and determined unable to leave the facility without supervision. On or about December 21, 2014, Resident #1 successfully eloped from the facility and was returned shortly after without harm. The facility failed to ensure a safe environment resulting in the potential for harm and is a violation of Oregon Administrative Rules.",2,,,, +BH116909,50M228,RCF,4/27/2011,Staff discovered narcotic medications switched out with over the counter pain medication. RP2 admitted to switching the medication out and taking the narcotic medications for personal use. Resident #1 and Resident #2 had no observable negative outcome as a result of the incidents. The abuse was apportioned to RP2. Facility failed to provide a safe medication resulting in the loss of narcotic medications.,2,0,Not Substantiated,Substantiated,Financial abuse +BH118751,50M228,RCF,12/20/2011,"Resident #1's care plan required frequent checks and not to be left in wheelchair except for meals. On December 20, 2011, RP2 put Resident #1 in her/his wheelchair around 9:45 AM and did not check on her/him until noon. Resident #1 was found on floor with minor injury. RP2 was found substantiated for abuse.",2,0,Not Substantiated,Substantiated,Neglect +BH121745,50M228,RCF,10/14/2012,"Resident #1 was a new resident who required administration of medication including injections and blood glucose readings. Witness #2 was assigned to administer medication on October 14, 2012, however had not been delegated to administer injections for this particular resident. After corresponding with RP2, Resident #1 administered the injection her/himself. There was no observable negative consequence as a result of the incident. The facility failed to provide a safe medication administration system resulting in the potential for harm to Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH134122,50M228,RCF,6/18/2013,RP2 was being trained by RP3 for medication administration when RP3 was called away by management. RP2 administered the wrong medications to Resident #1 resulting in being transported to the hospital for observation. The facility failed to provide a safe environment resulting in the potential for moderate harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH146854,50M228,RCF,4/18/2014,"Resident #1 was given Resident #2's medication in error and was transported to the hospital for treatment. Reported Perpetrator #2 was found responsible for the medication error, which is considered neglect of care and constitutes abuse. The facility failed to maintain a safe medication administration system. This failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +CO15080,50M228,RCF,2/12/2015,"The facility failed to adequately assess and intervene when Resident #1 sustained a fall with injury. Resident #1 fell again two days later and required hospital care. This failure is a violation of resident rights, which is considered neglect of care, and constitutes abuse.",3,300,,,Neglect +BH152708,50M228,RCF,4/29/2015,"The facility to adequately ensure Resident #1 and Resident #2 were treated with dignity and respect, in relation to comments made by Reported Perpetrator #2. This failure is a violation of Oregon Administrative Rules.",2,,,, +OR0000986000,50M228,RCF,7/29/2015,,1,,,Substantiated, +BC145656,50M247,RCF,1/8/2014,"Resident #1 was given medication to reduce fever but it was not charted in the Medication Administration Record (MAR). No progress notes were written by staff regarding medication orders or declining health. As a result, Resident #1 experienced pain, fever and discomfort. The facility failed to provide a safe medication administration system and update Resident #1's care plan for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES145647,50M264,RCF,1/8/2014,"Resident #1 had two documented cases of aggression towards other residents and the facility failed to implement interventions to prevent future altercations. Resident #1 continued to show aggressive behavior and hit Resident #2 in the face producing a bruise. These failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",2,,,,Neglect +RD116445,50M265,RCF,1/27/2011,"On 1/27/11 at approximately 6am, Resident #1 was found on the floor, next to the bed, awake but with a swollen wrist. He/she was transported to the hospital with a diagnosis of a fractured wrist. Resident #1 was care planned to have a pressure alarm attached while in bed; however the alarm was found connected to the bed but not to him/her, and the alarm did not sound. Staff failed to check his/her alarm during their shifts.",2,0,,,Neglect +RD117802,50M265,RCF,8/8/2011,"Three bubble packs of narcotic medications for Resident #1, Resident #2, and Resident #3 were discovered missing on 8/8/11, three days after delivered and checked in by staff; and the corresponding narcotic log pages were also missing. The theft of narcotic medications was the act of an unknown individual.",2,0,Not Substantiated,Substantiated,Financial abuse +RD129361B,50M265,RCF,2/8/2012,"Resident #1 was care planned needing extensive assistance for medication administration and most medications were either crushed and/or liquid, except a stool softener tablet. Between 1/22/12 - 1/27/12, Resident #1's lower lip was observed to be swollen and the gum line was sore to the touch. It was discovered that Resident #1 didn't swallow the tablet and it partially dissolved in his/her lip causing swelling and pain. The facility failed to assess and intervene and failed to provide appropriate methods of medication for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RD120110,50M265,RCF,4/19/2012,"On or about 4/18/12, facility staff discovered that narcotic pain medication had been ordered regularly for up to five different residents; however they were not logged into the narcotic log or the pharmacy order book. Reported Perpetrator 2 (RP2) admitted to ordering narcotic pain medications over the course of four-to-six months and keeping the narcotics for him/herself. RP2 is responsible for the theft of narcotic pain medications. The facility failed to have a safe medication and auditing system that prevented theft or misuse of medications. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +RD134735,50M265,RCF,8/24/2013,"Resident #1 climbed a tree in the backyard of the facility, scaled a fence and was found two blocks away. No injuries were reported. Resident #1's Service Plan stated staff was to monitor him/her when in the secure backyard because of exit-seeking behavior. The facility failed to follow Resident #1's Service Plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD150414B,50M265,RCF,1/15/2015,"Resident #2 was found an unknown number of times where he/she had stained and dirty clothing, was observed with dried feces on his/her catheter tubing and in the private area, and in his/her bedding. The facility failed to provide service to Resident #2 resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD150414E,50M265,RCF,1/15/2015,Resident #5's teeth were not brushed on a regular basis and were observed to have white coating over the top teeth and a yellow coating over the bottom teeth. The facility failed to ensure adequate teeth brushing for Resident #5. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +BO152256,50M265,RCF,4/30/2015,Video surveillance evidence shows Reported Perpetrator 2 (RP2) removing pain medications from the medication cart and then going to his/her purse/bag. RP2 also signed the MAR for pain medication administration at times that don't match the date/time on video surveillance. RP2 is responsible for the theft of pain medications which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication administration system and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +DL129671,50M267,RCF,10/1/2011,"The facility failed to appropriately handle Resident #1_x001A_s personal incidental funds, and failed to appropriately use his/her monies. A Hoyer lift was purchased with Resident #1_x001A_s money; however he/she wasn_x001A_t care planned for it nor had caregivers used the equipment with Resident #1. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,300,,,Financial abuse +DL129676,50M267,RCF,1/1/2012,"Resident #1's dentures were noted to be lost in January, 2012 and were found in May, 2012. The facility failed to replace his/her dentures for approximately four months, which may have contributed to some weight loss. The failure is a violation of Oregon Administrative Rules.",2,0,,, +DL147454,50M267,RCF,6/18/2014,"The facility failed to take more timely reasonable precautions to provide a safe environment to protect residents from Resident #2's behaviors. Resident #2 had physical altercations with Resident #1, Resident #3 and Resident #4. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +DL148093,50M267,RCF,8/8/2014,"Resident #1 had history of wandering, exit seeking, and wanted to ""go home."" He/she eloped from the facility through an unlocked door and open garage door, which didn't have an alarm. He/she was gone for approximately 45 minutes and returned by law enforcement without injury. The facility failed to take reasonable precautions and failed to have a functional door alarm to provide a safe environment for Resident #1 and his/her known exit seeking behavior. The failures are a violation of Oregon Administrative Rules.",2,,,, +MV117000,50M268,RCF,5/11/2011,Resident #1 had a history of elopement and required monitoring due to cognition. Resident #1 was found wandering the streets. The facility failed to monitor Resident #1 consistent with evaluated needs after elopement occurred. The facility failed to follow Resident #1's service plan resulting in the potential for harm.,2,0,,, +MV104693,50M268,RCF,6/25/2010,"Resident #1 was identified as a fall risk and required reminders to use walker. On or about June 25, 2010, Resident #1 got up and walked to kitchen after call light was not answered. Resident #1 fell resulting in bruising. Investigative findings revealed that the resident's call light was not working. The facility failed to have a functioning call light resulting in fall with bruising to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MV120339,50M268,RCF,6/19/2012,"Resident #1 had a diagnosis related to cognition, is non weight bearing and required assistance with a hoyer lift. A large bruise was found on Resident #1's chest area on or about June 18, 2012. Internal investigation was conducted and unable to determine how bruise occurred. Investigation determined that the bruise was caused by external factors such as a hoyer lift or sit to stand. The facility failed to provide a safe environment resulting in bruising to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MV146906,50M268,RCF,4/23/2014,Resident #1 was administered another resident's medication in error. Facility notified necessary parties and monitored with no documented negative consequences. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.,2,,,, +MV149209A,50M268,RCF,2/13/2014,"Resident #1 was administered the wrong medication resulting in a negative outcome that required medical attention. The facility also failed to administer medication as ordered based on facility documentation. Facility failed to ensure the preservation of documents when Resident #1's February Medication Administration Record could not be located. The failures are violations of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted however not issued due to the timeframe between the investigation and processing by the Department.",2,,,,Neglect +MV149209B,50M268,RCF,2/13/2014,"The facility failed to ensure timely medical treatment after Resident #1 experienced a fall with injury that required transportation to the hospital. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however not issued due to the timeframe between the investigation and processing by the Department.",3,,,,Neglect +KF151790,50M300,RCF,6/27/2015,"Resident #1 had a history of wandering into the facility kitchen and care planned to be redirected. On or about June 27, 2015, RP2 was verbally inappropriate after Resident #1 returned to the kitchen. The facility failed to ensure Resident #1 was treated with dignity and respect and is a violation of Oregon Administrative Rules.",2,,,, +KF151844,50M300,RCF,7/2/2015,RP2 was observed to be verbally inappropriate when redirecting Resident #1 back to her/his room. The facility failed to ensure Resident #1 was treated with dignity and respect and is a violation of Oregon Administrative Rules.,2,,,, +KF151847,50M300,RCF,7/7/2015,"Resident #1 had a history of staying up at night and sleeping during the day. A sleep aide was prescribed, however only given on one occasion during the month of June 2015. Documentation record for June also showed 19 incidents of Resident #1 not receiving her/his morning medication due to sleeping or refusing. The facility failed to ensure a safe medication administration system to address Resident #1's sleep that affected medication administration in a timely manner and is a violation of Oregon Administrative Rules.",2,,,, +KF152130,50M300,RCF,7/13/2015,Resident #1 resided in a secure memory care facility and eloped on two known occasions. Facility documentation showed that the facility failed to address Resident #1's behavior to prevent future incidents resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF152280,50M300,RCF,7/29/2015,Resident #1 resided in a secure memory care community and was observed to leave the front door behind a visitor. The facility was able to redirect Resident #1 back into the facility without incident. The facility failed to ensure a safe and secure environment resulting in the potential for harm.,2,,,, +KF152314,50M300,RCF,7/31/2015,Resident #1 resided in a secure memory care community and was observed wandering outside the facility. The facility was able to redirect Resident #1 back into the facility without incident. The facility failed to ensure a safe and secure environment resulting in the potential for harm.,2,,,, +KF152342,50M300,RCF,7/31/2015,"Complainant reported RP2 pulled Resident #1 by the arm, causing pain while escorting back to her/his room. Resident #1's care plan identifed her/him as a wanderer. Progress notes and witness testimony revealed Resident #1 had a recent change of condition and was highly sensitive. Resident #1's care failed to identify her/his change of condition and provide staff direction around her/his sensitivity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO15243,50M300,RCF,11/19/2015,"Findings of the Residential Care Facility Initial Licensure Survey (#Z3ZD11) completed on November 19, 2015 determined that the Facility is not in substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility_x001A_s noncompliance placed residents at risk for harm. See Survey for specific details. RCFCD15-014",3,,,,Neglect +KF152985,50M300,RCF,9/29/2015,"Resident #1 experienced six (6) falls within a three month period. The facility failed to adequately assess and update the care plan to address Resident #1's falls resulting harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,250,,,Neglect +CO13083,50R009,RCF,5/23/2013,"The facility failed to evaluate and monitor Resident #1 regarding his/her falls; failed to implement new interventions to minimize future falls; and failed to update his/her service plan. Resident #1 had falls with injuries. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC147703,50R009,RCF,7/1/2014,"Five residents had money and personal belongings stolen. The thefts occurred between April thru July 2014, however was not reported until approximately 7/10/14. The facility failed to investigation and report the incidents; failed to provide a lockable storage space; and failed to implement safety measures to prevent future thefts. The failures are a violation of resident rights, are considered neglect of care resulting in financial exploitation which constitutes abuse.",3,350,,,Financial abuse +BC148451,50R009,RCF,8/8/2014,"Five residents had money, debit card and/or personal belongings stolen. The thefts occurred approximately between 7/20/14 thru 8/8/14. There had been multiple prior thefts at the facility with a lack of adequate changes to address it. The facility failed to investigate and report the incident and failed to take reasonable precautions to implement safety measures to prevent future thefts. The failures are a violation of resident rights, are considered neglect of care resulting in financial exploitation which constitutes abuse.",3,300,,,Financial abuse +BC148493,50R009,RCF,9/6/2014,Reported Perpetrator 2 (RP2) was administering medications to Resident #1 and RP2 was overheard speaking with a forceful voice. Resident #1 had become combative flailing his/her arms. RP2 was concerned that he/she may have had a dry pill in his/her mouth and tried to hold one of his/her hands down to check. Resident #1 was noted with a skin tear and was treated quickly. It cannot be confirmed the skin tear was a result of RP2. Resident #1 was not treated with respect and dignity. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.,2,,,, +BC149548,50R009,RCF,12/5/2014,"On 12/5/14, Resident #1 moved into the facility. On 12/6/14, his/her narcotic medications were discovered missing. RP2 and RP3 deny taking any medications. The facility failed to provide a safe medication administration system to prevent theft of narcotic medications. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC150071,50R009,RCF,1/26/2015,"The facility failed to provide a safe medication administration system. Resident #1 went without his/her blood pressure medication from 8/27/14-9/16/14. Resident #2 needed medications crushed and the facility failed to timely follow up for accurate doctors orders. Resident #1 and Resident #2 experienced unreasonable discomfort due to the facility's failures. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BC150795,50R009,RCF,3/28/2015,"Resident #1 discovered medications missing from his/her room. An investigation revealed an unknown individual is responsible for the theft of medications, which constitutes financial exploitation. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC153820,50R009,RCF,7/31/2015,"In July 2015, Reported Perpetrator 2 (RP2) took a check of Resident #1's and tried to cash it. It is unknown if the check was cashed or if the transaction was stopped. The facility failed to self-report the incident to the local APS office and failed to provide facility documentation of their internal investigation. The failures are a violation of Oregon Administrative Rules and the failures exposed residents to harm.",2,,,, +AL135158,50R023,RCF,7/24/2013,Reported Perpetrator #2 (RP2) failed to place pillows on the edge of Resident #1's bed as stated in the service plan. RP2 later found Resident #1 on the floor after he/she had rolled out of bed. RP2 and W2 then transferred Resident #1 into his/her wheelchair. However RP2 then failed to tilt Resident #1's wheelchair back causing Resident #1 to fall a second time. Resident #1 injured his/her head and was sent to a hospital for treatment. RP2 failed to follow the service plan twice leading to two falls and an injury to Resident #1. RP2's failures are considered neglect of care and constitute abuse. The facility failed to protect Resident #1 from neglect of care. This failure is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Neglect +AL146935,50R023,RCF,11/25/2013,"Staff were reported to be rough with putting Resident #1's shoe on his/her foot. His/her ankle became discolored, swollen and painful. The facility failed to ensure staff treated Resident #1 with caution due to his/her naturally deformed left ankle. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Physical Abuse +AL147911A,50R023,RCF,7/19/2014,"Resident #1 was not administered his/her anti-nausea medication for approximately three and a half days. The facility ran out of his/her medication and is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL147911B,50R023,RCF,7/19/2014,"Resident #1's transfer poles were removed when he/she began exhibiting generalized weakness. This took away his/her ability to exercise and became more dependent. The facility returned the transfer poles at physician orders but placed one next to the recliner, but not the one by his/her bed. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL153113,50R023,RCF,10/12/2015,"RV1 has a history of exit seeking from the facility. RV1 regularly attempts to look for a way to leave the facility. RV1 was to be frequently monitored by facility staff to know his/her whereabouts within the facility. RV1 eloped from the facility out the main gate on October 8, 2015. RV1 was observed leaving the facility and staff returned RV1 to the facility without injury. The facility placed RV1 at risk of harm.",2,,,, +MS135467,50R038,RCF,12/20/2013,"The facility failed to provide sufficient staff to meet the 24 hour scheduled and unscheduled needs of their residents. Resident #1 fell, and the only staff member at the facility was not strong enough to help Resident #1 transfer off the floor. Resident #1 was left on the floor for over 30 minutes until another staff member arrived at work. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MM135393,50R040,RCF,12/11/2013,It was reported that Reported Perpetrator 2 (RP2) was rough when assisting residents. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,1,,Not Substantiated,Substantiated, +MM146530,50R040,RCF,2/14/2014,"Reported Perpetrator 2 (RP2), Reported Perpetrator 3 (RP3) and Witness 3 performed an ear lavage on Resident #1 under RP2's supervision. Resident #1 showed signs of significant pain. RP2 led both RP3 and Witness 3 to perform the task without responding to Resident #1's pain. Reported Perpetrator RP2 was found responsible for physical abuse. The facility failed to protect Resident #1 from physical abuse. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Physical Abuse +MM146948,50R040,RCF,4/25/2014,Resident #1 was being assisted by Reported Perpetrator 2 (RP2) up from the toilet. RP2 requested Witness #2's assistance. Witness #2 heard a smack and Resident #1 asked who hit him/her. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +MM148866,50R040,RCF,10/9/2014,"Resident #1 sustained bruising from an unknown cause on three occasions. The facility documented that the bruising probably occurred during transfer. Resident #1's care plan was not updated between March 6, 2014 and October 14, 2014. The facility failed to update Resident #1's care plan and provide a safe environment. The failures are a violation of Oregon Administrative Rules.",2,,,, +MM149187,50R040,RCF,11/6/2014,Resident #1 lives in the Residential Care portion of the facility and Witness #6 lives in the Independent Living portion. They have been married for many years and have been involved in multiple altercations at the facility. The facility failed to implement adequate interventions regarding Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES104920,50R046,RCF,7/19/2010,Resident #1_x001A_s particular type of TV was stolen from his/her room on or about 7/15/10.,2,0,Not Substantiated,Substantiated,Financial abuse +ES116410,50R046,RCF,2/20/2011,"Resident #1's service plan was not followed for toileting and hygiene needs related to incontinence management resulting in several occasions of soiled clothing, linens, and a strong odor in room. Resident #1's service plan was not followed when he/she needed to be escorted outside due to his/her physical capabilities.",2,0,,, +ES105955,50R046,RCF,12/3/2010,Resident #1's theft of money occurred by an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +ES118466,50R046,RCF,10/28/2011,"Thefts of money were reported for Resident #1, Resident #3 and Resident #4; and theft of debit card for Resident #2. A staged video surveillance in Resident #1's room identified Reported Perpetrator 2 (RP2) in his/her room searching the locations where he/she kept cash. Facility call light records identified that Resident #1 did not call for assistance on the night RP2 searched Resident #1's room. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules. RP2 is found responsible for the theft of money and the abuse is apportioned to RP2.",3,0,Not Substantiated,Substantiated,Financial abuse +ES120126B,50R046,RCF,5/22/2012,The facility had an order for barrier paste; however it was unavailable and an alternate barrier cream was used. The facility failed to ensure a prescribed medication was available. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO13120,50R046,RCF,8/29/2013,"A re-licensure survey completed on August 29, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to ensure service plans were implemented and reflected resident's current status and interventions; failed to evaluate and monitor a significant change of condition and monitor residents related to falls and skin issues and failed to provide a safe medication administration system relating to sliding scale insulin. Resident #1 experienced skin tears as a result of a fall. Resident #3 experienced a worsening foot wound. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES151535,50R046,RCF,2/11/2015,"The facility and Reported Perpetrator 2 (RP2) failed to provide oversight and monitoring of Resident #1_x001A_s change of condition. Resident #1_x001A_s lab results were not timely followed up on from 2/11/2015 and he/she was hospitalized on 2/25/2015. Resident #1 required multiple interventions to correct his/her condition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +ES151060B,50R046,RCF,4/23/2015,"The facility failed to follow Resident #1's care plan regarding his/her continuous O2 needs. Resident #1 experienced a shortness of breath. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES164377,50R046,RCF,1/19/2016,The facility failed to ensure staff treated Resident #1 with dignity and respect and be free from potential for harm. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +CO16069,50R046,RCF,2/9/2016,"The facility failed to evaluate, implement interventions, monitor, and ensure an RN assessment regarding Resident #1_x001A_s change of condition. Resident #1 experienced uncontrolled pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV149016,50R068,RCF,10/21/2014,"Resident #1 was told she/he must stay in her/his room after vommiting. Facility progress notes confirmed the resident was told to stay in her/his room on three known days. There was no physican or nurse consultantion to determine if making the resident stay in her/his room was appropriate. The facility failed to asssure residents' rights, and is a violation of Oregon Administrative Rules.",2,,,,Involuntary Seclusion +MM121222,50R078,RCF,9/1/2012,"On August 4, 2013, Resident #1 sustained an injury fall while being transferred with the assistance of one staff person. The facility failed to appropriately update Resident #1_x001A_s service plan relating to transfers resulting in a fall with injury. The facility also failed to timely assist Resident #1 with two-person transfers requiring him/her to wear disposable undergarments for bathroom needs. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MM121728,50R078,RCF,11/26/2012,"Resident #1 returned to the facility with a medication change decreasing a prescribed medication. As a result of incorrect dosage, Resident #1 was sent to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted; however, one will not be issued due to the extended period of time between the incident date and processing by the Department.",3,,,,Neglect +MM146108,50R078,RCF,2/4/2014,"Resident #1 had medication taken from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM148898,50R078,RCF,10/13/2014,Resident #1 reported narcotic medications missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated, +MM148901,50R078,RCF,9/22/2014,Resident #1 reported Oxycodone pills missing from his/her apartment. An unknown individual was determined to be responsible for the theft of Resident #1's medication which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MM153194,50R078,RCF,10/15/2015,The facility failed to adequately provide a safe medication administration system. Resident #1 received an incorrect medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +CO11111,50R085,RCF,9/13/2011,"Following the re-licensure survey on June 13, 2011, a Letter of Agreement was implemented on July 8, 2011 to retain the services of a Registered Nurse (RN) consultant with weekly progress reports and that the licensee receive written approval from the RN Consultant before admitting any new residents. However, after thoughtful review and consideration of the survey revisit completed on September 15, 2011, this license condition is being imposed immediately.",3,0,,,Neglect +MV118031,50R085,RCF,8/20/2011,"Resident #1's incomplete order of his/her sliding scale insulin from the pharmacy was not discovered upon receipt. Resident #1 had a high reading and he/she was administered an incorrect dose bringing levels to a dangerous low. Staff monitored and responded appropriately and Resident #1 was ultimately transported to the hospital for treatment, and returned within that day. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +A civil penalty was not issued due to this complaint being based in part of the License Condition #RCFCD11-009.",3,0,,,Neglect +WB132234,50R085,RCF,1/21/2013,"On 1/21/13, it was discovered that medication was missing from Resident #1's bottle. An unknown person is responsible for the loss of his/her medication, which is considered theft and constitutes financial exploitation. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +WB132380,50R085,RCF,2/8/2013,"Resident #1 was scheduled to receive a medication once weekly every Wednesday. Reported Perpetrator 2 (RP2) administered Resident #1 two doses of medication on Saturday and Sunday, and then again on the scheduled day, Wednesday. There was no observable negative outcome to Resident #1. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,0,,, +CO13112,50R085,RCF,8/13/2013,"The facility failed to evaluate and monitor Resident #2's change of condition. Resident #2 experienced abdominal pain and three emergency room visits. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +WB121971,50R085,RCF,12/21/2012,"Resident #1 was put on alert charting for increased confusion and wandering on 11/30/12 and taken off alert charting 12/9/12; however no change was made to his/her care plan. On 12/21/12, Resident #1 was found in the facility parking lot and was brought back to the facility without incident. He/she had previous history of wandering and exit seeking. The facility failed to adequately care plan to keep Resident #1 safe. The failures are a violation of Oregon Administrative Rules.",2,,,, +WB132003,50R085,RCF,12/27/2012,"On 12/28/12, it was discovered that Resident #1 was missing medication. Reported Perpetrator 2 (RP2) admitted that he/she gave Resident #1 an incorrect amount of medication. Documentation does not reveal that Resident #1 suffered any ill effects. The facility failed to ensure a safe medication administration system pertaining to Resident #1's medication administration.",2,,,, +WB132528,50R085,RCF,1/1/2013,"Between January 6th and January 12th, 2013 the facility identified 87 medication errors involving 26 residents. None of the residents experienced adverse effects from these errors. However, the facility failed to maintain and safe medication administration system. This failure is a violation of Oregon Administrative Rules.",2,,,, +WB135028B,50R085,RCF,10/29/2013,Resident #3 received twice the prescribed dose of her medication on three days in October 2013. The facility failed to administer medication as prescribed. This failure is a violation of Oregon Administrative Rules.,2,,,, +WB147392,50R085,RCF,6/1/2014,"The Facility failed to take reasonable precautions and maintain a safe medication administration system to ensure a qualified and delegated staff person was on shift to check levels and administer Resident #1's medication as ordered. On 6/1/14, Resident #1 was transported to the hospital. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +WB149031A,50R085,RCF,7/28/2014,"According to facility documentation and witness statements, Resident #1 showed indicators of exit seeking and leaving the building. On 7/28/14, Resident #1 left the facility and was found approximately an hour later in a field near the facility. Resident #1 had no observable negative outcome. The facility failed to properly conduct a 30 day assessment and update his/her care plan related to exit seeking behaviors, causing a risk for harm. The facility failures are a violation of resident rights and Oregon Administrative Rules.",2,,,, +MV147990,50R085,RCF,7/27/2014,Resident #1 was in his/her room and engaged in a conversation with Reported Perpetrator 2 (RP2) who allegedly got upset and threw a newspaper at Resident #1. RP2 failed to treat Resident #1 with respect and dignity. The facility failed to ensure resident rights which a violation of Oregon Administrative Rules.,2,,,, +BC148781,50R091,RCF,9/29/2013,Resident #1 reported that Reported Perpetrator 2 (RP2) screamed an inappropriate comment at him/her and also that RP2 shoved banana in his/her mouth. RP2 denied both allegations. RP2 had a history of being rude and impatient with residents according to witness statements. Witness statements also said that Resident #1 had a history of being excitable and exaggerating events. The facility failed to assure Resident #1's resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC153912,50R091,RCF,12/9/2015,"Resident #1 was transported to the hospital due to a heart attack. Resident #1 had been prescribed a medication. It was found that Resident #1 had not received the medication for the month of November 2015. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES117010,50R108,RCF,4/19/2011,"Resident #1_x001A_s physician ordered that the facility hold his/her blood thinning medication for two days due to high test levels. The facility failed to hold this medication as ordered resulting in Resident #1 being transported to the hospital and contributed to his/her other health factors. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES133174,50R108,RCF,5/7/2013,"It was reported Resident #1 grabbed Resident #2's hands and shook them, which was the third altercation instigated by Resident #1 toward Resident #2 in a 30 day period. Though Resident #1 was experiencing changes in behavior due to two separate medical conditions; the facility failed to implement increased monitoring in both Resident's Care Plans, resulting in the facility failing to intervene when Resident #1's condition changed. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES135526,50R108,RCF,12/25/2013,"Resident #1 reported $300 taken from her/his room. There was no lockbox available in the resident's room. The facility failed to provide a safe environment and failed to provide a required lockbox in Resident #1's room. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +ES147358,50R108,RCF,6/6/2014,"Resident #1 reported missing an item from her/his room. A search of the room was unable to find the item. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +ES146349,50R108,RCF,3/2/2014,"Resident #1 was on end of life care. The facility failed to follow the end of life care instructions and took the resident to the hospital for treatment resulting in $14,000 bill. The failure is a violation of Oregon Administrative Rules. The facility paid for the hosptial bill.",2,,,, +ES147544,50R108,RCF,6/25/2014,"Resident #1 reported $160 cash missing from her/his wallet. Witness testimony and facility documentation revealed Resident #1 had not spent the money. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was held responsible for the theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES148352B,50R108,RCF,8/30/2014,Resident #1 had an orchid plant go missing from her/his room. Witness #5 reported she/he threw it away at Resident #1's request however Witness #8 indicated that the resident would not have asked staff to throw it away. Facility failed to replace the plant as promised in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148352D,50R108,RCF,8/30/2014,"The facility failed to adequately address the strong smell of urine coming from the adjoining bathroom from her/his room. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES147195,50R108,RCF,5/23/2014,"Resident #1 had a history of bowl incontinence and playing with her/his feces. The facility failed to adequately care plan resulting in continued bowl incontinence that required bathing. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES147543,50R108,RCF,6/25/2014,"Resident #1 experienced a thumb injury after the heaving lid on the storage bench in her/his room slammed down. After the incident, the facility fixed some of the sotrage benches to keep them from slamming shut, but forgot several other residents' rooms including Resident #1 resulting in the potential for further injury. The facility failed to ensure a safe environment resulting in the potential for harm and is a violation of Oregon Administrative Rules. The facility corrected the error during the course of the investigation.",2,,,, +ES147578,50R108,RCF,6/30/2014,RP2 did not appropriately notify staff and/or home health after Resident #1's dressing became soiled. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES150251,50R108,RCF,2/11/2015,"The facility failed to adequately address Resident #1's aggressive behavior resulting in continued negative behavior affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES149364,50R108,RCF,11/23/2014,"The facility failed to ensure a safe environment resulting in an altercation with Resident #1 and Resident #2. Resident #2 sustained a small scratch. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES150494,50R108,RCF,3/8/2015,"The facility failed to ensure staffing was sufficient in number at the time of the incident in order to follow Resident #1's plan. Resident #1's behavior affected other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES152126,50R108,RCF,7/17/2015,Reported Perpetrator 2 (RP2) was rough when cleansing Resident #1 after toileting. RP2 failed to treat Resident #1 with dignity and respect. The facility failed to ensure resident rights and is a violation of Oregon Administrative Rules.,2,,,, +ES152082,50R108,RCF,7/8/2015,"Reported Perpetrator 2 (RP2) was rough while providing care to Resident #1 resulting in pain the following day and too sore to sit down. RP2 was known to be abrupt with residents. The facility failed to take reasonable precautions, failed to adequately investigate RP2's actions and behaviors, and failed to report. The failures are a violation of resident rights, are considered neglect of care resulting in physical abuse. RP2's actions are considered rough treatment and constitute physical abuse.",2,,Substantiated,Substantiated,Neglect +CO13024,50R121,RCF,1/24/2013,"A re-licensure survey completed on January 24, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: The facility failed to evaluate changes of condition, provide RN assessments, develop interventions and monitor residents who experienced changes of condition. Resident #1 experienced pain and anxiety. Resident #5 experienced a urinary tract infection and a lower leg fracture. Resident #7 experienced severe weight loss and multiple falls with minor injuries. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC133053,50R121,RCF,4/11/2013,Resident #1 was found on the floor of his/her room in the early morning. He/she had sustained a scrape to their elbow. Resident #1 was unable to summon help by pressing his/her alarm pendant because it had not been reset after a previous activation. The pendant required resetting by care staff in order to function. The facility failed to provide a safe environment due to Resident #1_x001A_s alarm pendant not being reset. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC146428,50R121,RCF,3/16/2014,"Resident #1 reported his/her billfold missing that contained cash, two credit cards and social security card. Resident #2 reported cash missing from his/her room. Resident #3 reported cash and his/her Kindle missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC149284,50R121,RCF,10/23/2014,"Resident #1 had money go missing in from his/her room. The cash was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC148841,50R121,RCF,9/20/2014,"Resident #1 had checks taken from his/her room. The checks were used in attempts to purchase merchandise in a different state, and Resident #1 had no knowledge of this. The checks were taken by an unknown individual, and this unknown individual is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC153653,50R121,RCF,9/27/2015,"Resident #1, #2, #3, and #4 had medication go missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC153654,50R121,RCF,11/1/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +CO11027,50R125,RCF,2/22/2011,"The facility failed to provide a safe medication and treatment system, failed to service plan and monitor specific to resident needs, and failed to investigation injuries of unknown cause.",3,0,,,Neglect +MV116910,50R125,RCF,4/21/2011,Resident #1 did not receive adequate toileting and hygiene assistance when dried fecal matter was discovered on his/her skin.,2,0,,,Neglect +MV117150,50R125,RCF,6/1/2011,Resident #1's narcotic medication change was ordered on 5/27/11; however was not updated on his/her June Medication Administration Record (MAR) resulting in him/her receiving the incorrect dosage on 6/1/11.,2,0,,, +MV117077,50R125,RCF,5/18/2011,"Resident #1 had a scheduled narcotic pain medication each morning at 7am. On 5/18/11 at 9am, he/she was observed to be anxious which was usually caused by pain or discomfort. Reported Perpetrator 2 (RP2) failed to administer Resident #1 his/her scheduled narcotic pain medication at 7am resulting in Resident #1 suffering unreasonable discomfort. RP2's actions are considered neglect of care. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +CO12091,50R125,RCF,7/27/2012,"The facility failed to ensure Resident #4_x001A_s change of condition was monitored, evaluated and referred to the facility Registered Nurse. Resident #4 experienced worsening of a skin tear. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV134260,50R125,RCF,8/28/2013,Resident #1 left the facility without assistance and staff didn't notice for several hours. Resident #1 was found and returned without injury. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,,,, +MV135284B,50R125,RCF,12/2/2013,"Resident #1's service plan indicated Resident #1 needed a facility staff member to escort him/her while outside of the facility at all times. However, facility staff were told to leave Resident #1 at a local place of business and come back to the facility when additional staff were needed. The facility failed to follow Resident #1's service plan. This failure is a violation of Oregon Administrative Rule.",2,,,, +MV146991B,50R125,RCF,5/2/2014,"Resident #1 entered the facility as a fall risk and fell frequently due to forgetting that he/she cannot walk resulting in injuries to arms and knees. He/she continued to fall, however his/her care plan was not updated with new interventions. The facility failed to care plan appropriately for falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO14193,50R125,RCF,8/20/2014,"The facility failed to evaluate, monitor, and ensure a RN assessed and intervened when Resident #3 experienced a significant change of condition. Resident #3 suffered unrelieved pain and had a severe weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA147804,50R125,RCF,5/27/2014,"Staff attended to Resident #1's hand injury that was sustained during a transfer on the day shift of 5/27/14; however failed to report or document the injury. Approximately 6 hours after the incident, treatment was provided for his/her skin tear. The facility failed to ensure staff reported the injury for timely treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV149557,50R125,RCF,12/10/2014,Resident #1's care plan instructs staff to use gait belt for all transfers. Reported Perpetrator 2 (RP2) attempted to position Resident #2 into his/her wheelchair by holding onto his/her hips and pulling him/her into position. RP2 failed to follow Resident #1's care plan. The facility failed to ensure staff followed his/her care plan. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +DA148630,50R125,RCF,9/5/2014,"Resident #1 moved his/her power chair forward at a face paced causing it to pin him/her arm against the bathroom counter. Resident #1 experienced bruising, swelling and pain. It was known that he/she had some difficulty managing his/her power chair and bumping into things. The facility failed to monitor and implement interventions to ensure Resident #1's safety for mobility. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MV150674,50R125,RCF,3/15/2015,"On 3/15/15, Reported Perpetrator 2 (RP2) pushed Resident #1 in his/her wheelchair and didn't know his/her leg was dragging until RP2 heard moaning and grimacing on Resident #1's face. RP2 did not formerly report the incident that day, therefore there was no assessment completed on Resident #1's leg. Resident #1 suffered unreasonable discomfort, and after assessment on 3/16/15 he/she was diagnosed with a sprain. RP2's failure is considered neglect of care which constitutes abuse. The facility failed to ensure staff reported incidents and changes of conditions and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +MV150676,50R125,RCF,2/1/2015,"Resident #1's physician electronically ordered a prescription for symptoms related to his/her condition; however the facility did not except the electronic ordering system and waited for the written signature order. Resident #1 did not get his/her medication as ordered for approximately one month and his/her condition worsened. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + +This incident warranted a civil penalty, however the incident date occurred prior to the change of management effective 3/1/15.",3,,,,Neglect +MV152856,50R125,RCF,7/24/2015,"Resident #1 had money and property go missing from his/her room. They were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV153916,50R125,RCF,11/23/2015,"Residents #1 and #2 had money and an item go missing from their room. The property was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident's #1 and #2 property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +MV153920,50R125,RCF,12/10/2015,"The facility failed to adequately administer oxygen to Resident #1 as prescribed. Resident #1 ran out of oxygen while at his/her medical provider resulting in very low oxygen saturations. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +SV103599,50R126,RCF,2/14/2010,"Within two days, four reports of theft occurred in rooms of Residents #1 - #4. These residents had access to lock boxes but were not utilizing them. The facility was unable to determine a viable suspect, but appeared to be an isolated incident. Residents were reminded to utilize the lock boxes.",2,0,Not Substantiated,Substantiated,Financial abuse +CO11120,50R126,RCF,10/20/2011,"The Facility failed to ensure Resident #1 and Resident #2 were monitored based on their health conditions; failed to ensure significant changes of condition were evaluated and referred to the facility RN; and failed to provide and RN assessment. Resident #1 experienced unrelieved pain. Resident #2 experienced a severe weight loss. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +MV118647,50R126,RCF,11/29/2011,Resident #1's wedding ring went missing from his/her room. A result of the investigation determined that an unknown individual was responsible for the theft of his/her property. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +SV129325A,50R126,RCF,2/24/2012,Resident #1_x001A_s PRN narcotic medication had been discontinued; however it was not disposed of timely or updated on the Medication Administration Record. Resident #1 complained of pain and was administered one PRN narcotic medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +SV129325B,50R126,RCF,2/24/2012,Resident #1's service plan documented orders to provide wound care with instructions; however the facility failed to assure that staff were delegated this task. The facility failed to comply with nursing delegation requirements. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV151828,50R126,RCF,7/5/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV152468,50R126,RCF,4/27/2015,"Reported Perpetrator #2 (RP2) failed to follow Resident #1's care plan and utilize a gait belt while assisting Resident #1 with a transfer. Resident #1 fell and sustained an ankle injury. RP2 is responsible for neglect of care, which constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +RD116666,50R128,RCF,1/24/2011,"One resident of the Facility failed to receive medication that he/she needed and another resident received a medication that he/she did not need. A Facility staff member mistook which resident should have received his/her PRN medication and administered the medication to the wrong resident. The resident who received the medication slept the rest of the day and the resident who did not receive medication did not have relief from his/her symptoms, causing unreasonable discomfort.",2,0,,, +RD129072,50R128,RCF,12/30/2011,RP2 used inappropriate verbal language towards Resident #1. The facility failed to ensure Resident #1 was treated with dignity and respect resulting in loss of dignity. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BO145868,50R128,RCF,1/12/2014,"The facility failed to place the bathroom pull cord within reach of Resident #1 for use when he/she is on the toilet. Resident #1 attempted to transfer off the toilet in an attempt to reach the pull cord and suffered a fall causing pain. The facility failed to place a manually operated emergency call system within reach of Resident #1 in the toilet and bathing room. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon administrative rules.",2,,,,Neglect +ES117062,50R171,RCF,5/22/2011,"Resident #1 kept multiple family heirlooms and jewelry in a locked box in a locked cabinet in his/her room, and the keys were kept in a place that staff had access to. These items were reported missing on 5/24/11. An unknown individual wrongfully took these personal items from Resident #1.",2,0,Not Substantiated,Substantiated,Financial abuse +ES116889,50R171,RCF,5/1/2011,Resident #1's physician ordered medication patch was not followed as directed. Facility staff members were not trained to perform the task. Resident #1 suffered additional pain.,2,0,,,Neglect +ES118721,50R171,RCF,11/23/2011,"Resident #1's pain medication of approximately 120 tabs was taken from the facility by an unknown individual. The medication system was noted to be inadequate with no auditing system. The facility failed to provide a safe medication administration system that prevented theft or misuse of medications. The failures are a violation of resident rights, is considered neglect of care and constitutes financial abuse.",2,0,,,Financial abuse +ES152415,50R171,RCF,8/8/2015,"Resident #1 had items go missing from his/her room. The items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES164267,50R171,RCF,12/1/2015,Reported Perpetrator #2 (RP2) slapped Resident #1 on the arm. RP2 is responsible for physical abuse. The facility failed to provide a safe environment for Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated, +RB120220A,50R202,RCF,6/3/2012,"Resident #1 had a history of agitation and care planned related to how to bath to reduce agitation. On or about June 3, 2012, RP2 attempted to bath Resident #1 using the tub instead of the usual shower. Resident #1 became agitated and flailed arms. Bruising was noted after the incident. The facility failed to ensure service plan was being followed resulting in minor harm to Resident #1. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care and constitutes abuse.",2,0,Not Substantiated,Substantiated,Neglect +RB146144,50R202,RCF,2/17/2014,Reported Perpetrator 2 (RP2) was interrupted during a medication pass and accidentally gave Resident #1 another residents' medication. The error was discovered promptly and notifications were made to doctor and family. Resident #1 was observed and placed on alert charting. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.,2,,,, +RB146548,50R202,RCF,3/25/2014,"On 3/25/14, Resident #1 eloped out of a propped open door of the facility and was found on the ground with a large skin tear on his/her head. He/she was transported to the hospital for treatment and died the next day. Resident #1 had approached and attempted to open the same door a couple weeks prior. The facility failed to appropriately intervene, and implement and document safety measures when he/she experienced a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +CO12088,50R216,RCF,7/12/2012,"The facility failed to monitor and evaluate Resident #3 and Resident #4 consistent with their needs, including changes of condition. Resident #3 experienced unrelieved pain and Resident #4 had a pattern of falls with injuries, including a fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,,Neglect +DA153477,50R216,RCF,10/23/2015,The facility failed to ensure Resident #1 was treated with dignity and respect. Facility staff refused to give Resident #1 his/her food until he/she gave up his/her TV remote control. This failure is a violation of Oregon Administrative Rules.,2,,,, +BH120825,50R229,RCF,7/16/2012,Reported Perpetrator 2 was found responsible taking cash from Residents #1 - #17 resulting in a substantial loss of money for said residents. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +BH133766,50R229,RCF,7/3/2013,"Resident #1 was given his/her medications to take with him/her when leaving for several days; however one medication was not included. Resident #1 experienced weight gain as a result and required a physician appointment. Reported Perpetrator 2 (RP2) packaged his/her medications, missing one. RP2's failures are considered neglect of care, constituting abuse. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +BH164148,50R229,RCF,11/21/2015,"Facility staff instructed RV2 by letter and in person that he/she is only to have contact with RV1 in common areas of the facility such as the library or café and not in RV1's room. On or about November 21, 2015 RV2 was found in RV1's room. The facility's failure to provide a safe environment is a violation of the Oregon Administrative Rules.",2,,,, +MS116872,50R234,RCF,4/29/2011,"The facility failed to properly plan care and provide service pertaining to Resident #1_x001A_s needs and risk of aspiration. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS117374,50R234,RCF,7/5/2011,Resident #1 discovered 76 narcotic medications missing from her/his room and an internal investigation started. The facility failed to provide a safe environment resulting in the loss of Resident #1's narcotic medication. An unknown person was found responsible for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MS135334,50R234,RCF,11/29/2013,Resident #1 requested assistance to the restroom. He/she was assisted to the restroom and when done called out for assistance back to bed. Reported Perpetrator 2 (RP2) did not respond due to him/her falling asleep. Resident #1 felt he/she waited an unreasonable amount of time before help came. The facility failed to assist Resident #1 in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS147875,50R234,RCF,7/21/2014,"On or about July 21, 2014, Resident #1 requested a pain medication and was denied because the facility did not have any available. Witness testimony and facility documentation revealed the facility failed to reorder the medication in a timely manner. The facility failed to administer medication as ordered resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH104985,50R251,RCF,8/9/2010,"Reported Perpetrator 2 (RP2) was observed being frustrated when providing care to residents who suffered from memory loss, and would use an abrupt, loud tone when speaking.",2,0,,, +BH118712,50R251,RCF,12/8/2011,Resident #1 was care planned with behaviors and interventions including PRN medications. He/she became agitated during care and attempted to kick Reported Perpetrator 2 (RP2). RP2 and Witness 2 did not attempt the interventions.,2,0,,, +BH129375B,50R251,RCF,12/4/2011,Resident #2 had a tendency to use his/her call light frequently. Reported Perpetrator 2 (RP2) instructed staff to place the call light out of his/her reach or not to respond to it at times when he/she used it a lot. His/her regular care plan instructed him/her to use the call light for assistance. The facility failed to implement a temporary care plan addressing safety issues during these high frequently call light use. The facility failed to provide a safe environment for Resident #1. The failures are a violation of Oregon Administrative Rules.,2,0,,, +BH129375C,50R251,RCF,12/4/2011,"Resident #3's service plan was not followed for the correct placement of the tab alarm and for not following to lock the brakes of his/her special positioning chair. Resident #3 fell out of the chair and sustained bruising. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH129375D,50R251,RCF,12/4/2011,"Resident #3 was service planned for night caregivers to keep him/her in sight and take him/her with staff when doing rounds. Resident #3 was found on the floor in his/her room and sustained bruising. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH153698,50R251,RCF,6/5/2013,The facility failed to provide an adequate medication administration system. Resident #1 was given his/her medication but facility staff failed to watch Resident #1 actually take their medication. Resident #1 missed doses of medication as a result. This failure is a violation of Oregon Administrative Rules.,2,,,, +BF103730,50R256,RCF,3/8/2010,A resident of the Facility experienced a loss of his/her medication when it was removed from a locked safe within the Facility. The Facility was not able to determine who was responsible for the missing medication.,2,0,,,Financial abuse +BH120059,50R256,RCF,5/11/2012,"Resident #1 eloped from the facility on May 11, 2012. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH120245,50R270,RCF,5/31/2012,RP2 was heard being verbally inappropriate with Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH132596,50R270,RCF,3/6/2013,There was a resident to resident altercation with Resident #1 and 2. Both residents had a history of aggression and were care planned for close monitoring. No staff were present to monitor at the time of the incident. Facility staff failed to follow the care plans. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH132803B,50R270,RCF,3/29/2013,"The facility did not provide Resident #1 with needed medical supplies, which were on backorder, placing Resident #1 at risk of potential harm. The facility failed to provide medical treatment as ordered. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH134214,50R270,RCF,12/21/2012,Resident #1 was a known fall risk and care planned for assistance with transfers. RP2 failed to adequately assist Resident #1 with a transfer resulting in a fall with injury. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care and constitutes abuse.,2,,Not Substantiated,Substantiated,Neglect +BH134139,50R270,RCF,7/2/2013,"Resident #1 was admitted to the secure unit on 07/01/13. On 07/02/13 and 07/03/13, Resident #1 was able to leave the facility unattended. Resident #1 was returned to the facility right away after each incident with no injuries noted. Resident #1's Assessment/Evaluation stated he/she was a risk for elopement. Resident #1's photograph was not entered into the Elopement Risk Book until after the second incident. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +BH146124,50R270,RCF,2/17/2014,"On or about February 15, 2014, Resident #1 wandered into Resident #2's room resulting in a physical altercation. Resident #1 had a history of agitated behavior and wandering into other residents' room. The facility failed to address and update the care plan after Resident #1's behaviors continued. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH153254,50R270,RCF,6/19/2015,Resident #1 has a diagnosis of dementia was taken to an outside appointment unescorted. The facility was unaware of Resident #1's whereabouts until she/he was discovered sleeping in her/his room around 5:00 AM the following day. The facility failed to ensure Resident #1's safety while attending an outside appointment and is a violation of Oregon Administrative Rules.,2,,,, +BH153458,50R270,RCF,8/16/2015,The facility failed to ensure a safe environment resulting in the elopement of Resident #1. Resident was returned without injury. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH153358,50R270,RCF,6/16/2015,"Resident #1 had a history of sexually inappropriate behaviors and was care planned to address it. The facility failed to adequately monitor Resident #1 as care planned resulting in inappropriate sexual touching of another resident. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse.",2,,,,Neglect +BH150425,50R270,RCF,1/22/2015,RV1 has a history of wandering and required safety checks according to his/her care plan. RV2 has a history of behaviors when he/she is upset or anxious. RV1 entered RV2's room and refused to leave. RV2 grabbed RV1's wrists causing reddening and discoloration. The facility failed to provide a safe and secure environment which is considered neglect of care and constitutes abuse.,2,,,,Neglect +BH164276,50R270,RCF,12/28/2015,"RV1 was on alert charting as a new admission and due to being an elopement risk. On December 27, 2015 RV1 was described as anxious and exit seeking. On December 28, 2015 RV1 eloped from a secure area of the facility without staff knowledge. The facility's failure to provide a safe environment is a violation of the Oregon Administrative Rules.",2,,,, +BH153690,50R270,RCF,4/4/2015,,2,,,,Neglect +BH146884,50R271,RCF,4/16/2014,"Resident #1's watch disappeared from his/her room between 4/15/14 - 4/16/14 and may have been stolen from a staff person. It was valued at $2000 to $3000. Reported Perpetrator 2 (RP2) admitted to taking $20 from Resident #1 but did not admit to taking the watch. RP2 is responsible for the theft of money, constituting abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS132635A,50R274,RCF,3/13/2013,Resident #1 eloped from the facility and was found down the street. He/she was a known exit seeker. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ST116036,50R275,RCF,12/25/2010,"Staff heard the outside door alarm sound, but did not thoroughly search the courtyard. Resident #1 was outside in the rain for an undetermined time before being found. Resident #1 had a history of falls and wandering, and service planned to monitor whereabouts. The facility failed to provide a safe environment resulting in harm to Resident #1.",2,0,,,Neglect +ST117375,50R275,RCF,4/30/2011,"Resident #1 was assessed as a high fall risk and experienced a recent history of falls. The facility failed to adequately care plan for falls resulting in Resident #1 being transported to the hospital for treatment of a fracture from a fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST118204B,50R275,RCF,9/29/2011,Resident #2 and Resident #3 had known behaviors and experienced a physical altercation in which Resident #3 sustained injury to her/his arm. The facility failed to follow the residents' service plan resulting in minor arm.,2,0,,,Neglect +ST118611,50R275,RCF,12/2/2011,"Resident #1 has a history of getting in to other people spaces and Resident #2 has a history of aggressive behavior when others invade her/his space. Resident #2 slapped Resident #1 after being touched. The facility failed to follow residents' service plans. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ST129312,50R275,RCF,2/14/2012,"Resident #1 resided in a secured memory care facility. Resident #1 left the facility unattended through an unlocked gate and walked down the street disrupting traffic. Police were called and the resident returned without injury. The facility failed to provide a safe environment resulting in the potential for serious harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +ST121000,50R275,RCF,9/1/2012,"Resident #1 had a history of distrust thinking that people try to steal things from her/him. Staff keep Resident #1's door closed to prevent other residents from wandering in. On or about September 1, 2012, Resident #1's door was left open and Resident #2 walked in resulting in a physical altercation with minor injury. The facility failed to adequately care plan and provide clear direction to staff regarding Resident #1's behavior resulting in a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ST121050,50R275,RCF,8/4/2012,"The facility failed to adequately care plan for falls after Resident #1 experienced multiple falls, some with injuries. The fall on August 4, 2012 resulted in transportation to the hospital for treatment of a pelvic fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST121070,50R275,RCF,9/12/2012,"The facility failed to adequately care plan for falls on a cognitively impaired resident resulting in multiple falls, some with injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ST121221A,50R275,RCF,10/2/2012,Resident #1 was care planned for two hour checks and maintenance on an assistive devise that collects bowel waste. Witness testimony and facility documentation revealed that appropriate maintenance checks were not being followed as care planned. Facility failed to follow care plan as directed resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ST121221B,50R275,RCF,10/2/2012,"Resident #1 has a medical condition that requires her/him to follow a strict diet. Resident #1 was able to access and consume a staff member's lunch which resulted in stomach cramps. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,0,,,Neglect +ST121749,50R275,RCF,11/29/2012,"Resident #1 and Resident #2 were room mates who had a past history of verbal altercations. On or about 11/29/12, staff entered the residents' room and observed them in a verbal and physical altercation. Resident #2 suffered a skin tear as a result. The facility failed to appropriately care plan regarding Resident #1 and Resident #2's behaviors resulting in minor harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ST121896,50R275,RCF,12/11/2012,Resident #1 was involved in several altercations with other residents during a short period of time. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ST133090,50R275,RCF,4/28/2013,"Resident #1 was found completely soaked in urine on two separate occasions. His/her care plan stated Resident #1 was to be assisted with toileting every 1-2 hours. Staff witnesses, however stated it was every 2 hours. The plan as written was not addressing the issue. The facility failed to properly care plan for Resident #1's incontinence. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST133949,50R275,RCF,7/27/2013,"The facility did not post signs near the side exit door stating it is a locked facility nor did they provide information to visitors about not allowing residents to leave the facility. Resident #1 followed a visitor out the side exit door, started walking down the street and fell, bruising his/her wrist. Resident #1's Service Plan stated he/she was known to exit seek. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST133961,50R275,RCF,7/27/2013,Residents #1 - #5 received a double dosage of their medications on the evening shift on 07/27/13. The residents were evaluated the following day when the error was discovered. No adverse effects were noted and the residents were placed on alert for monitoring any change of behavior. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +ST133995,50R275,RCF,7/31/2013,"Resident #1 and Resident #2 experienced two physical altercations resulting in injury to Resident #1 on both occasions. The facility failed to appropriately monitor and follow the care plan resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +ST134300,50R275,RCF,8/31/2013,"Resident #1 pushed Resident #2 down while walking down the hall. Resident #2 experienced swelling to her/his knee. Resident #1 has a history of aggressive behavior. The facility failed to appropriately monitor and care plan for Resident #1's behavior resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +ST134398,50R275,RCF,9/10/2013,"Resident #2 has a history of aggressive behavior and expressed anger towards her/his roommate, Resident #1 on multiple occasions. The facility failed to appropriately monitor and timely address the issue resulting in a physical altercation between the residents. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ST134674,50R275,RCF,10/9/2013,"Resident #1 hit Resident #2 in the stomach and held her/his arms until staff intervened. Resident #1 had a history of aggressive behavior and previous recent altercation with Resident #2. The facility failed to adequately care plan and monitor resulting in harm to Resident #2. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +ST134939,50R275,RCF,11/3/2013,"Resident #1 was a high fall risk and care planned for staff assistance with mobility. The facility failed to follow the care plan resulting facial bruising from a fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST135383,50R275,RCF,12/11/2013,Resident #1 had a medical device that required constant monitoring and maintenance. Facility had an hourly check off list for staff when they checked on the device. Witness testimony and facility documentation revealed that the check off list was not maintained. Investigation determined the facility failed to ensure Resident #1's device was being monitored resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +ST145644,50R275,RCF,1/9/2014,"The facility failed to assess and implement additional interventions around Resident #1's continued weight loss. Resident #1 lost 25 pounds over the course of a few months. The facilities failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",3,300,,,Neglect +ST146285,50R275,RCF,3/5/2014,"Resident #1 had a history of aggressive behavior towards staff and residents. The facility failed to adequately care plan and monitor Resident #1 resulting in continued negative behavior affecting other residents. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ST148859,50R275,RCF,9/26/2014,"Resident #1 had a history of aggressive and agitated behavior. The facility failed to adequately address and monitor Resident #1's behaviors in a timely manner resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST149425,50R275,RCF,10/8/2014,Resident #1 had a prescription for medication that required an order to be filled. Staff submitted the request for refill to the physician's office instead of the pharmacy resulting in a delay in receiving the medication. Resident #1 was given another pain medication until the correct medication was filled. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.,2,,,, +ST149742,50R275,RCF,12/31/2014,"Resident #1 had a history of aggressive behavior and hit a resident in the head. The facility failed to adequately monitor Resident #1 and is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST150018,50R275,RCF,1/9/2015,Resident #2 swatted Resident #1 on the arm after Resident #1 attempted to take Resident #2's assistive devise for the second time. There was no harm as a result of the incident. The facility failed to adequately monitor Resident #1 resulting in negative behavior by Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,,, +ST150439,50R275,RCF,3/1/2015,"The facility failed to adequately monitor Resident #1 on March 1, 2015 resulting in an altercation with Resident #2 and is a violation of Oregon Administrative Rules.",2,,,, +ST150440,50R275,RCF,2/27/2015,The facility failed to adequately monitor Resident #1 as care planned resulting in an altercation with Resident #2 and is a violation of Oregon Administrative Rules.,2,,,, +ST150920,50R275,RCF,4/13/2015,"Resident #1 had experienced recent falls and was identified as a fall risk. Resident #2 had a history of wandering into other residents' rooms. On or about April 13, 2015, staff responded to yelling and found Resident #1 on the floor in her/his room after observing Resident #2 leave. The facility failed to address Resident #2's wandering which contributed to Resident #1's fall that required transportation to the hospital for treatment of a fracture. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,400,,,Neglect +ST150996,50R275,RCF,4/18/2015,"The facility failed to adequately monitor Resident #1's behavior and provide timely interventions resulting in continued negative behavior affecting others. The failures are violations of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST152410,50R275,RCF,8/4/2015,"The facility failed to adequately care plan Resident #1 resulting in a second altercation when found in another resident's bed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ST153608,50R275,RCF,11/8/2015,The facility failed to adequately monitor Resident #1's wandering as care planned resulting in an altercation with Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB105695,50R276,RCF,11/19/2010,Reported Perpetrator 2 (RP2) was verbally inappropriate to Resident #1 and spoke in a raised voice.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HB118584,50R276,RCF,11/28/2011,"Resident #1 was care planned to have the tab alarm on at all times, except when home health visited. On 11/28/11 around 2pm, home health left as well as Reported Perpetrator 2 (RP2) at end of shift. At approximately 6pm, Resident #1 fell and sustained some bruising and skin tear above his/her eye. RP2 failed to attach Resident #1's tab alarm; and subsequently other staff during the four hour window. RP2 and facility staff failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,Substantiated,Substantiated,Neglect +HB118779,50R276,RCF,10/20/2011,"The facility failed to adequately care plan related to Resident #1's falls, some resulting in injuries. The failure is a violation of Oregon Administrative Rules.",2,0,,,Neglect +HB121219,50R276,RCF,9/25/2012,"Resident #1 had very fragile skin. On 9/25/12, he/she was found to have reddened skin below his/her eyes and a small cut on his/her lower lip. Reported Perpetrator 2 (RP2) stated he/she washed Resident #1's face and brushed his/her teeth. The facility was aware of RP2's history of providing care with emphasis on speed rather than resident safety. The facility failed to protect Resident #1 from rough treatment. RP2 is found responsible for neglect of care, which constitutes abuse. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,Substantiated,Substantiated,Neglect +HB121464,50R276,RCF,10/28/2012,"Resident #1 bruised easily. Between 8/31/12 and 10/29/12, he/she had several bruises of unknown origin. Resident #1 was known to move furniture; was observed to have another resident attempt to assist him/her; he/she held hands with other residents; and observed grabbing at other residents' food causing other residents to push away or grab at Resident #1. The facility failed to properly plan care for his/her known behavior to reduce bruising. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB146496,50R276,RCF,3/26/2014,"On 3/25/14, Reported Perpetrator 2 (RP2) grabbed Resident #1's arm when his/her behavior escalated causing a skin tear. There was a similar unreported incident on 12/2/13. RP2 failed to follow Resident #1's care plan of interventions. RP2's actions are considered physical abuse. The facility failed to provide a safe environment and failed to report to APS which are violations of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +HB159980,50R276,RCF,1/21/2015,"Reported Perpetrator 2 (RP2) touched (""hit"" or ""slapped"") the back of Resident #1's hand when he/she didn't let go of a cup. Resident #1 had no observable skin markings, was unaware of the incident, and denied pain. RP2 did not respond to investigation interview. Therefore the description of the ""hit"" or ""slap"" is based on a statement from one direct witness. RP2 failed to treat Resident #1 with respect and dignity. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,,, +MM129752,50R277,RCF,3/18/2012,"The facility failed to address Resident #1's incontinence brief size with the POA in a timely manner resulting in continued soaked clothing and skin breakdown. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,0,,,Neglect +MS146098,50R278,RCF,2/18/2014,"Resident #1 had a history of being verbally and physically aggressive with staff. Resident #2 had a history of being verbally and physically aggressive with staff and residents. Resident #2 and his/her former roommate did not get along. Three days after Resident #1 was moved in with Resident #2, Resident #2 hit Resident #1 in the cheek and he/she was visibly upset. The facility failed to take reasonable precautions to provide a safe environment for residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS146915,50R278,RCF,2/6/2014,"Resident #2 had a history of not getting along with his/her roommates; and had a history of physical aggression and anger issues toward residents and staff. Two days after Resident #1 moved into Resident #2's room, Resident #2 grabbed Resident #1's wrists and hit him/her on the back. The facility failed to take reasonable precautions to provide a safe environment for residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS146953,50R278,RCF,9/16/2013,"The facility failed to implement effective interventions and monitor Resident #1 and Resident #2 for known behaviors and pain indicators leading to behaviors, resulting in an altercation between the two. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS146990,50R278,RCF,5/5/2014,"The facility failed to follow the care plan to supervise Resident #2 around food to prevent behaviors. Resident #2 hit Resident #1 more than once on the arm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +MS147978,50R278,RCF,7/31/2014,Resident #1 and Resident #2 had an altercation. Resident #1 had prior history with behaviors. The facility failed to provide a safe environment and the failures are a violation of Oregon Administrative Rules.,2,,,, +MS150461,50R278,RCF,3/3/2015,"Resident #1 had aggressive behaviors mainly directed toward Resident #2. There were multiple episodes of Resident #1's aggression toward Resident #2, sometimes within a single day, over a period of several weeks. Resident #2 was afraid/anxious that staff may not be able to protect him/her from Resident #1. Other residents were also fearful of Resident #1's behaviors. The facility failed to take reasonable precautions and implement interventions to protect residents from harm to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES105267A,50R279,RCF,9/12/2010,RP2 made derogatory comments to residents while providing care. RP2 was suspended and later terminated. The facility failed to protect residents from inappropriate comments resulting in loss of dignity.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +ES105267B,50R279,RCF,9/12/2010,"RP2 was observed roughly putting in Resident #1's dentures. Witness testimony revealed that Resident #1 had a history of being resistive when staff assist with dentures. Facility documentation showed no staff direction on assisting with dentures and measures when Resident #1 became resistive. The facility failed to adequately care plan surrounding denture assistance resulting in minor harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES116600,50R279,RCF,3/24/2011,"The facility failed to monitor and intervene in a timely manner after Resident #1 experienced a significant change of condition that required transportation to the hospital for treatment. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES118305,50R279,RCF,10/23/2011,Resident #1 had a history of inappropriate sexual behaviors after experiencing a specific type of infection. The facility failed to appropriately care plan on how to address Resident #1's behaviors when it was identified she/he had an infection. This resulted in Resident #1 inappropriately touching Resident #2.,2,0,,,Neglect +ES129146,50R279,RCF,2/2/2012,"Resident #1 had a history of wandering into other residents' rooms and Resident #2 had a history of being possessive of room. Both residents_x001A_ care plans were adjusted to prevent Resident #1 from entering other residents_x001A_ rooms and keep other residents from entering Resident #2_x001A_s room. The updates were dropped off of the care plans when they were printed so care staff were unaware of new directions. On or about February 2, 2012, Resident #1 entered Resident #2's room resulting in Resident #1 sustaining a hip fracture from a physical altercation. The facility failed to have clear directions for care staff regarding Resident #1 and Resident #2 resulting in moderate harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES129522,50R279,RCF,3/15/2012,Resident #1 has thin skin that is prone to bruising and skin tears. RP2 held onto Resident #1's wrists while attempting to change. Bruising was noted after the incident. It was determined the facility failed to provide a safe environment resulting in bruising. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES120119,50R279,RCF,5/20/2012,"Resident #1 had a history of yelling. On or about May 20, 2012, Resident #1 was yelling while RP2 was providing care. RP2 placed her/his hand over Resident #1's mouth and told the resident to shut up. The facility failed to assure resident's rights resulting in loss of dignity. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES117901,50R279,RCF,9/5/2011,Resident #1 had delicate skin that bruises easily. RP2 heard an altercation between two residents and responded by removing Resident #1 from the situation. Resident #1 was later observed with bruising on her/his wrists. RP2 did not recall grabbing Resident #1 by the wrists when she/he removed the resident from the altercation. The facility failed to provide a safe environment resulting in bruising.,2,0,,, +ES132008,50R279,RCF,12/31/2012,Resident #1 appeared with bruising to his/her upper arms and hands. Resident #1 gave a description of the person who caused the bruising. The description matched Reported Perpetrator 2 (RP2). RP2 was the only person of the opposite sex working that hall. RP2 was found responsible for rough treatment which constitutes physical abuse. The facility failed to protect resident from rough treatment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +ES132760,50R279,RCF,3/23/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained a black eye. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES133238,50R279,RCF,5/14/2013,"Resident #1 is a known wanderer and Resident #2 had a history of agitation when Resident #1 wandered into Resident #1's room. Staff observed the residents in altercation after Resident #1 wandered into Resident #2's room. The facility failed to provide a safe environment resulting in harm to Resident #1. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES134579,50R279,RCF,9/27/2013,"Resident #2 was a known wanderer and entered Resident #1's room resulting in a large skin tear from a physical altercation. The facility failed to adequately care plan and provide a safe environment resulting in harm to Resident #1. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +ES134892,50R279,RCF,10/26/2013,"Resident #1 had a history of ongoing aggressive behavior resulting in numerous altercations. The facility failed to adequately address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +ES134675,50R279,RCF,10/7/2013,"Resident #1 has a history of agitation and combative behavior related to bathing and has a prescribed medication to calm her/him when in an agitated state. The facility failed to adequately care plan resulting in unnecessary agitation, affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES134810,50R279,RCF,8/1/2013,Complainant reported the facility was not proving adequate care to Resident #1. Witness statements and facility documentation revealed Resident #1 was often resistive to care. The facility failed to follow physician orders to administer and track fluid intake and submit report due to dehydration. The facility also failed to update the care plan related to Resident #1's condition. The failure is a violation of Oregon Administrative rules.,2,,,, +ES134084,50R279,RCF,8/2/2013,"Resident #1 was a known wanderer and Resident #2 had a history of aggressive behavior. A physical altercation occurred after Resident #1 entered Resident #2's room resulting in minor harm. There was one previous altercation between the two. The facility failed to adequately address residents' behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES134480,50R279,RCF,9/14/2013,RP2 was observed being overly affectionate towards Resident #1; kissing and hugging. RP2 was suspended and later terminated. The facility failed to assure resident rights and is a violation of Oregon Administrative Rules.,2,,,, +ES133815,50R279,RCF,7/15/2013,Resident #1 had a diagnosis related to cognition and often refused toileting and hydration assistance. Facility failed to adequately address the resident's behaviors and was later moved to another facility that was able to provide the higher level of care that the resident needed.,2,,,,Neglect +ES146240,50R279,RCF,3/3/2014,"Resident #1 has a medical condition that required routine monitoring and testing of blood sugar levels. Witness testimony and facility documentation revealed the facility failed to adequately monitor and intervene after the resident consistently experienced low blood sugar levels resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES145916,50R279,RCF,1/28/2014,Witness reported RP2 was verbally abusive to Resident #1. RP2 was heard telling Resident #1 that she/he was going to hell and that her/his parents were in hell. Resident #1 became tearful and upset by the comments. RP2 was found responsible for verbal abuse and is a violation of resident rights. THe facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +ES145810,50R279,RCF,1/19/2014,"Resident #1 and Resident #2 had a history of altercations. Resident #2 also had a history of getting into Resident #1's room. On or about January 19, 2014, Resident #2 entered Resident #1's room and an altercation occurred. The facility failed to adequately address residents' behavior resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES146291,50R279,RCF,2/4/2014,"Resident #1 suffered five falls over four months. The facility implemented additional interventions, but failed to document two of these falls in Resident #1's care plan and only completed a facility investigation into one fall. These failures are a violation of Oregon Administrative Rules.",3,,,, +ES148064,50R279,RCF,8/6/2014,"The facility failed to provide a secure environment for Resident #1. The alarm on the exit door did not function and Resident #1 was able to elope from the facility. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES148890,50R279,RCF,10/9/2014,"The facility failed to administer medication to Resident #1 as ordered. Resident #1 was administered incorrect medication which exacerbated her condition and required hospital treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES148012,50R279,RCF,8/3/2014,The facility failed to notify Resident #1's treating physician when his/her blood sugar level rose to 356 on July 30th 2014. Resident #1 had a medical order to notify Resident #1's doctor if his/her blood sugar rises above 350. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES147640A,50R279,RCF,7/6/2014,"The facility failed to assess and implement adequate interventions around Resident #1s falls. Resident #1 experienced a change of condition and fell three separate times, with the third fall requiring hospital treatment. This failure is a violation or resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES147640B,50R279,RCF,7/6/2014,The facility failed to document Resident #1's treatment records when they administered his/her medication. This is a violation of Oregon Administrative Rules.,2,,,, +ES148123,50R279,RCF,8/13/2014,"The facility failed to adequately care plan related to falls for Resident #1. An initial fall involving Resident #1 resulted in a left hip fracture and Resident #1 went through rehabilitation at a different facility. Upon return, the facility did not implement any fall prevention measures. Resident #1 fell again and fractured his/her right hip. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES149503,50R279,RCF,12/6/2014,"The facility failed to adequately monitor Resident #1 and Resident #2. Resident #1 was care planned to be monitored to prevent him/her from entering other residents rooms. Resident #2 was known to show aggression to other residents and is protective of his/her room. Resident #1 wandered into Resident #2's room and attempted to get into the bed. Resident #2 hit Resident #1 in the face causing a bloody mouth to Resident #1, and a skin tear to Resident #2's hand. This failure is a violation or Resident Rights, is considered neglect of care, and constitutes abuse.",2,,Not Substantiated,,Neglect +ES145557,50R279,RCF,12/31/2013,"The facility failed to monitor Resident #1 and Resident #2 adequately. Resident #1 entered Resident #2's room. Resident #2 became upset and punched Resident #1 in the face. Both residents had shown aggression towards each other in the past. This failure is considered neglect of care, which constitutes abuse, and is a violation or Oregon Administrative Rules.",2,,,,Neglect +ES148378,50R279,RCF,9/1/2014,"The facility failed to adequately intervene when Resident #1 showed signs of aggression towards other residents. No changes to Resident #1's care plan were made despite Resident #1 having a history of aggression towards others. Resident #2 was hit by Resident #1. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +ES150184,50R279,RCF,2/9/2015,"The facility failed to administer Resident #1's pain patch as ordered. The facility also failed to implement interventions around Resident #1's aggressive behaviors when exhibiting additional pain symptoms. Resident #1 punched Resident #3 and pushed Resident #2 down. These failures are considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES159901,50R279,RCF,1/11/2015,"The facility failed to adequately monitor Resident #2 as indicated in his/her care plan. Resident #2 was able to encounter Resident #1 without care giver supervision and an altercation ensued. Resident #1 was punched in the face after being pushed to the ground. This failure is considered neglect of care, which is considered abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES159795,50R279,RCF,1/2/2015,"The facility failed to adequately monitor Resident #1 and Resident #2. Resident #1 wandered into Resident #2's room and an altercation ensued. Resident #2 punched Resident #1 several times in the head. This failure is a violation of resident rights, which is considered neglect of care, and constitutes abuse.",2,200,,,Neglect +ES151073,50R279,RCF,4/25/2015,"The facility failed to adequately assess and intervene in relation to Resident #1's history of aggression towards other residents. Resident #1 wandered into Resident #2's room and kicked Resident #2 in the shin when an altercation ensued. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES150380,50R279,RCF,2/23/2015,"The facility failed to adequately monitor Resident #2. Resident #2 has a history of aggression towards others and is care planned to be monitored for signs of anxiety and aggression. Resident #2 pushed down Resident #1 in a common room when no care staff were present. This failure is a violation of resident rights, which is considered neglect of care, and constitutes abuse.",2,350,,,Neglect +ES159949,50R279,RCF,12/1/2014,The facility failed to adequately provide a safe medication administration system. Resident #1 took a sip from orange juice that contained another resident's medication in it. Facility staff failed to ensure the other resident drank their orange juice and took their medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES151442,50R279,RCF,6/1/2015,The facility failed to adequately monitor Resident #1 and Resident #2. Resident #2 has a history of aggression towards other residents who wander into or close to his/her room. Resident #1 was pushed by Resident #2. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES151154,50R279,RCF,5/2/2015,"The facility failed to adequately assess and intervene in relation to Resident #1's aggressive behavior. Resident #1 had known aggression towards other residents and care providers. Resident #1 got into an altercation with Resident #2 and scratched Resident #2's nose. This failure is neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES150077,50R279,RCF,1/28/2015,"The facility failed to adequately monitor Resident #1. Resident #2 and Resident #1 had a history of altercations. Resident #1_x001A_s care plan called for monitoring when Resident #1 was interacting with other residents with noted behaviors. Resident #1 was able to enter Resident #2_x001A_s room where an altercations ensued. Resident #2 was knocked down and exhibited shoulder pain after the altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ES151571,50R279,RCF,6/11/2015,The facility failed to adequately monitor Resident #1 and Resident #2. The residents were involved in an altercation and Resident #2 pushed Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,,,Neglect +ES150585,50R279,RCF,3/14/2015,"The facility failed to adequately care plan for Resident #1_x001A_s wandering behavior. Resident #1 wandered into Resident #2's room and an altercation ensued. Both Residents slapped each other during the altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ES150617,50R279,RCF,3/17/2015,"The facility failed to adequately assess and intervene in relation to altercations involving Resident #1. Resident #2 and Resident #1 were involved in an altercation and slapped each other. No additional interventions were implemented for either resident. Both Residents were involved in another altercation five days later, and again slapped each other. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,, +ES150670,50R279,RCF,3/23/2015,"The facility failed to adequately assess and intervene in relation to Resident #1_x001A_s frequent altercations. Resident #1 has been involved in several altercations with other residents. He/she got into another altercation with Resident #2, and punched him/her in the face. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ES151211,50R279,RCF,5/8/2015,"The facility failed to adequately monitor Resident #1 and Resident #2. Resident #1 and #2 had been involved in a previous altercation, and Resident #1 was care planned to be kept away from Resident #2. The residents got into another altercation and slapped each other. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ES150642,50R279,RCF,3/20/2015,"The facility failed to adequately monitor Resident #1. Resident #1 and #2 were involved in an altercation. A care plan was completed to keep Resident #1 from wandering into other resident_x001A_s rooms. Resident #1 wandered into Resident #2_x001A_s room again and slapped him/her. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ES151277,50R279,RCF,5/8/2015,"The facility failed to adequately provide a safe environment in relation to Resident #2's sexual behaviors. Resident #2 was observed fondling Resident #1's breasts. The facility failed to implement any interventions for Resident #2's behavior. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES153516,50R279,RCF,10/16/2015,"Resident #1 had items go missing from his/her room. The items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +ES116871,50R280,RCF,5/2/2011,"The window alarm system had been disarmed inadvertently by facility staff opening a window in the kitchen, of which the facility had prior knowledge of. Resident #1 eloped from the facility by climbing out a window and returned without injury.",2,0,,, +FL117452,50R280,RCF,6/17/2011,"The facility failed to have a system in place to document the amount of pills received in from a family member for Resident #1. There was only one pill left when there should have been 4.5 pills remaining, thus being exposed to potential harm of a medication error.",2,0,,, +FL117867,50R280,RCF,8/30/2011,Resident #1 returned to his/her room from four days away to discover his/her watch and necklace missing. Several facility employees had access to his/her room. An unknown individual was responsible for taking these personal items of Resident #1.,2,0,Not Substantiated,Substantiated,Financial abuse +FL117696,50R280,RCF,8/10/2011,The facility failed to have a safe medication administration system by not having Resident #1's physician ordered narcotic pain medication available. Resident #1 experienced unreasonable pain for approximately five days.,2,0,,,Neglect +CO12006,50R280,RCF,12/7/2011,"The Facility failed to ensure significant changes of condition were evaluated, monitored, and referred to the facility RN; failed to provide an RN assessment and interventions; and failed to update the services plan as his/her needs changed. Resident #6 experienced severe weight loss. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +FL118228,50R280,RCF,10/13/2011,Resident #1 was administered a new ordered medication on 10/1/11 and he/she continued to be administered the old one until discovered on 10/13/11. There was no observable negative outcome to Resident #1. The facility failed to provide a safe medication administration system and this failure is a violation of Oregon Administrative Rules.,2,0,,, +FL129645,50R280,RCF,3/29/2012,Residents #1-#4 was not administered their ordered medication on 3/12/12. There were no observable negative effects to the residents. The facility failed to administer medications as ordered and the failure is a violation of Oregon Administrative Rules.,2,0,,,Neglect +FL118787,50R280,RCF,12/26/2011,"Resident #1 was alert and oriented with no issues related to cognitive function. Reported Perpetrator 2 (RP2) made statements about alleged military service; however he/she was never a member. RP2 made sexually inappropriate comments during conversations with Resident #1, and this conduct is considered sexual abuse. The facility failed to provide a safe environment.",2,0,Not Substantiated,Substantiated,Sexual abuse +FL120570,50R280,RCF,7/2/2012,Resident #1 wore his/her rings at all times at the facility; however were missing before the time of funeral home transport. An unknown individual is responsible for the theft of Resident #1's rings. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES120992,50R280,RCF,9/4/2012,Resident #1's call button went unanswered for approximately 20 minutes before care was provided and he/she felt undignified. The facility failed to provide a safe and homelike environment.,2,0,,, +FL121170,50R280,RCF,9/20/2012,"The facility failed to appropriately care plan for Resident #1's known routine to get up at night. Resident #1 had falls with injuries. The facility's failure to care plan appropriately resulted in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +FL120041,50R280,RCF,5/10/2012,The facilty failed to appropriately assess and intervene regarding Resident #1's behavior resulting in resident to resident altercation. The failures are a violation of Oregon Administrative Rules.,2,0,,, +FL121106,50R280,RCF,9/19/2012,"The facility failed to provide oversight and monitoring of Resident #1's change of condition; failed to appropriately care plan for falls; and failed to follow his/her service plan. Resident #1 suffered falls. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +ES133074B,50R280,RCF,4/14/2013,Resident #3's medications were administered to Resident #2. Resident #2's physician was contacted and he/she showed no observable negative signs or symptoms. The facility failed to administer Resident #2's medications as ordered.,2,,,, +ES133074C,50R280,RCF,4/14/2013,"Reported Perpetrator 2 (RP2) bought approximately $100 worth of Resident #1's pain medication. RP2 is found responsible for wrongfully buying his/her medications, constituting financial exploitation. The facility failed to provide a safe environment and that failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +FL120249,50R280,RCF,5/30/2012,"Staff and resident witnesses stated Reported Perpetrator 2 (RP2) used forceful caregiving with residents, at times resulting in discomfort to the residents. The facility failed to protect residents from rough treatment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for rough treatment, which constitutes physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +ES134041,50R280,RCF,8/4/2013,"The facility failed to provide timely medical treatment for Resident #1, following a fall which resulted in a fractured hip. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 is responsible for neglect of care, which constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +FL134413,50R280,RCF,9/11/2013,"Resident #1's bed headboard had an area that was rough, and Resident #1 sustained scratches to his/her head when their head rubbed against it. The facility failed to maintain a safe physical environment. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +FL135384,50R280,RCF,12/13/2013,"Resident #1 had a perscription run out and the facility failed to have the perscription refilled by a pharmacy. Due to this, Resident#1 did not receive his/her medication for several days. This failure is a violation of Oregon Administrative Rules.",2,,,, +CO14124,50R280,RCF,6/17/2014,"The facility failed to provide effective administrative oversight regarding residents_x001A_ quality of care and services as evidenced by the re-licensure revisit #1 survey (#QJYJ12) findings completed on June 17, 2014. See license condition #RCFCD14-007 for detail.",3,,,,Neglect +FL148546,50R280,RCF,9/9/2014,"Reported Perpetrator 2 (RP2) failed to administer pain medications as ordered to Resident #1 for his/her chronic pain, and anti-anxiety medications to Resident #2. The facility failed to ensure a qualified caregiver was present to administer medications correctly and failed to take reasonable precautions when RP2's actions continued. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES148725,50R280,RCF,9/24/2014,"Resident #1 was out of the facility for approximately 5-6 hours on 9/25/14, that evening noticed his/her money missing, and reported it to facility staff; however the facility failed to report suspected abuse to DHS and law enforcement. The investigation revealed that all witnesses denied taking the money. An unknown individual has been found responsible for theft, constituting financial exploitation which is considered abuse. The facility failed to ensure a lockable storage in Resident #1's room. The facility failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Financial abuse +FL148658,50R280,RCF,8/10/2014,"Several staff members falsified CBG records for residents, which created a risk of serious harm. The facility failed to provide a safe medication and treatment system, and failed to report the falsification to authorities as required by Oregon Administrative Rules. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +This incident warrants a civil penalty; however due to the fact that the facility is under a current license condition (#RCFCD14-007), a civil penalty will not be issued",3,,,,Neglect +ES149366,50R280,RCF,11/23/2014,The facility failed to provide a safe medication administration system to ensure Resident #1 received his/her medications as ordered. Resident #1 missed a single dose. The failure is a violation of Oregon Administrative Rules.,2,,,, +FL134977,50R280,RCF,11/5/2013,"Resident #1 reported money missing. An unknown individual is found responsible for the theft of money, which constitutes abuse. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +FL149600,50R280,RCF,12/11/2014,"Resident #1 was administered his/her discontinued medications as well as his/her new medication on four consecutive days (12/11/14 - 12/14/14). Resident #1 felt faint and fatigued on two of those days. Reported Perpetrator 2 (RP2) worked those same consecutive days and he/she failed to follow facility procedure. RP2's actions were neglectful, constituting abuse. The facility failed to provide a safe medication system and provide oversight of the administration of medications. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +FL149599,50R280,RCF,12/12/2014,"Reported Perpetrator 2 (RP2) took medication from Resident #1's bottle and gave it to Resident #2, as they are on the same medication and dosage. RP2 documented in error, resulting in Resident #1 being short a dose. Neither resident suffered any negative effects. The facility failed to provide a safe medication administration system to ensure proper medication administration. The failure is a violation of Oregon Administrative Rules.",2,,,, +FL135421,50R280,RCF,12/18/2013,"The facility failed to provide a safe medication system to ensure Resident #1's and Resident #2's medications were administered as ordered. Resident #1 went approximately four days without receiving pain patches prescribed for daily application. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES159924,50R280,RCF,1/13/2015,"On 1/13/15, Resident #1 hit Resident #2 on the shoulder. Resident #1 had a history of hitting Resident #2. Resident #1 had pain from dental work that day and was agitated by yelling of another resident. The facility failed to provide a safe environment and implement interventions regarding Resident #1's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES159934,50R280,RCF,1/14/2015,"Resident #1hit Resident #2 on the head with a pillow. Resident #2 had a history of yelling for hours. Resident #1 had behaviors and had teeth extracted earlier in the day. The facility failed to provide a safe environment and implement interventions regarding resident behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +FL150060,50R280,RCF,1/22/2015,"Resident #1 slapped Resident #2 in the face. They had a previous incident on 1/15/15. The facility failed to monitor and implement interventions for behaviors to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +FL148578,50R280,RCF,3/1/2014,The facility was not keeping accurate records regarding residents' personal incidental funds. Reported Perpetrator 2 was the person responsible for this record keeping. Several transactions were not accounted for with receipts. The facilities failure is a violation of Oregon Administrative Rules.,2,,,, +FL148849,50R280,RCF,10/5/2014,Reported Perpetrator 2 (RP2) did not administer all of Resident #1's medications on 10/5/2014. Resident #1 had no observable negative outcome. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.,2,,,, +ES150878,50R280,RCF,4/5/2015,"The facility failed to implement interventions and appropriately care plan regarding Resident #2_x001A_s known aggressive behaviors and that he/she had targeted Resident #1 before. Resident #2 was witnessed with his/her hands around Resident #1_x001A_s throat. The facility failed to provide a safe environment and the failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +FL149378,50R280,RCF,11/25/2014,"Resident #1 did not get his/her transdermal medication patch changed at ordered on 11/25/14, however did get it changed on 11/26/14. He/she was placed on alert charting for any ill effects. The facility failed to provide a safe medication administration system and violates Oregon Administrative Rules.",2,,,, +FL151404,50R280,RCF,5/28/2015,"Resident #1's pain medication was missing on the NOC shift count on 5/27/15. The medication cart was kept in a linen closet and multiple staff had keys to the closet. It was unknown if the medication cart was left unlocked or not. The facility failed to provide a safe medication administration system to prevent loss of medications. The failure is a violation of resident rights, is considered financial exploitation which constitutes abuse.",2,,,,Financial abuse +ES152058,50R280,RCF,7/13/2015,"Resident #2 exposed his/her genitals to Resident #1 who was deeply offended and upset. Resident #2 had recent history of engaging in sexual activity with another resident. The facility failed to monitor, appropriately care plan, and implement interventions regarding Resident #2's sexual behavior to provide a safe environment and protect other residents from unwanted sexual behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +FL152036,50R280,RCF,7/3/2015,"Resident #1 was not administered his/her doctor ordered mineral and he/she complained of increased fatigue, a symptom of depletion of that mineral. The facility failed to ensure a safe medication administration system to ensure orders are followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL152037,50R280,RCF,7/9/2015,"The facility failed to appropriately care plan Resident #1 as a new resident in regards to having medication available to administer as ordered for agitation and regarding his/her aggressive behaviors. Resident #1 was physically aggressive with Resident #2, twice in the same day, whom appeared frightened and needed calming. Resident #1 was allowed to spend approximately 30 minutes unsupervised with Resident #3 in his/her room and wasn_x001A_t assessed for any signs of injury following the unsupervised time. The facility failures resulted in harm and created a risk of harm to residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +FL151155,50R280,RCF,5/2/2015,"Resident #1 was moved to his/her room on several occasions after showing signs of agitation and was placed in a recliner in the reclining position for an undetermined amount of time. Resident #1 was not able to get out of the recliner nor able to call for assistance. The facility failed to implement interventions and care plan appropriately regarding his/her behaviors. The failures are a violation of resident rights, are considered abuse by means of involuntary seclusion and wrongful use of a restraint.",3,300,,,Involuntary Seclusion +FL151428,50R280,RCF,5/30/2015,"Resident #1's teeth had not been cleaned in a considerable amount of time. The facility failed to ensure his/her oral hygiene was provided. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL152338,50R280,RCF,7/31/2015,"Resident #1 entered Resident #2's room and an altercation ensued resulting in scratches to Resident #1's face and neck. Resident #1 was care planned to be supervised by staff at all times; however staff were provided one-on-one care tasks with other residents at the time. The facility failed to ensure Resident #1's care plan was followed to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +FL152492,50R280,RCF,8/14/2015,Resident #1 was found on the floor with his/her arm pinned in an assistive device and purple from lack of circulation. Medical evidence suggests that he/she had been down for at least 5 hours. The facility had a general practice to conduct rounds and check on every resident every two hours during the night. Reported Perpetrator 2 (RP2) failed to check Resident #1. RP2's actions are considered neglect of care which constitutes abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Neglect +FL152442,50R280,RCF,8/10/2015,"On 8/9/15, Reported Perpetrator 2 (RP2) was responsible for administering the swing shift medications to residents. RP2 was filling in for another employee and RP2 had not been trained to administer medications on swing shift. Resident #1, Resident #2, and Resident #3 were affected by this failure. The facility failed to ensure a qualified and trained staff person was administering medications to ensure a safe medication administration system. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +FL153178,50R280,RCF,10/14/2015,Resident #1 was agitated and hit Reported Perpetrator 2 (RP2) in the face. RP2 responded with slapping Resident #1 in the face. RP2's actions are considered physical abuse. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +FL151820,50R280,RCF,5/27/2015,"On 5/27/15, Resident #1 had an order to discontinue medications however he/she continued to be administered said medications until 7/1/15. His/her condition improved after medications were no longer administered as ordered. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL152180,50R280,RCF,7/17/2015,"The facility failed to implement and care plan interventions regarding Resident #2's physical behaviors resulting altercations with other residents. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +FL152618,50R280,RCF,8/26/2015,"Resident #2 and Resident #1 had an altercation. Resident #2 had prior altercations and had an increase in wandering. Staff were not able to monitor to redirect him/her. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL150875B,50R280,RCF,4/3/2015,Reported Perpetrator 2 (RP2) failed to treat residents with respect. The facility failed to ensure residents were treated with dignity and respect within a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES153235,50R280,RCF,10/14/2015,The facility failed to properly plan care about supporting Resident #1's need for emotional support during the day. The failures is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +FL153234,50R280,RCF,10/15/2015,"Resident #1 had a significant history of agitated behaviors. On 10/15/15, Resident #1 had an altercation with Resident #2, with no noted injuries. On this day, several other residents were highly agitated due to a new resident admission. The facility failed to appropriately care plan and implement interventions regarding Resident #1's behaviors to ensure resident safety and failed to monitor for safety. The failures are a violation of resident rights and violates Oregon Administrative Rules.",2,,,, +FL153091,50R280,RCF,10/3/2015,"The facility failed to perform an adequate assessment after Resident #1 was found on the floor from a fall and he/she expressed pain. Resident #1 was transported to the hospital later that morning and diagnoses with a fractured back. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO11034,50R281,RCF,1/27/2011,"The facility failed to develop and update interventions and monitor for their implementation, failed to ensure accurate assessments in order to update interventions, and failed to ensure physician_x001A_s orders for nutritional supplements were consistently carried out. Resident #2 and Resident #4 suffered ongoing severe weight loss. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +RD117775A,50R281,RCF,7/11/2011,"Resident #1 had a physician ordered medication to be administered two tablets daily at 7am and 4pm, and one tablet at 11am; however it was discovered that he/she was only administered one tablet three times per day. Resident #1 was noted to have increased symptoms.",2,0,,,Neglect +RD118292,50R281,RCF,9/22/2011,"Resident #1 was care planned to be assisted by staff whenever outside due to a history of falls outside. On 9/22/11, he/she went outside unassisted and fell sustaining injury. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,0,,,Neglect +RD145581,50R281,RCF,12/28/2013,Reported Perpetrator 2 (RP2) yelled very loud twice after Resident #1 grabbed RP2's head and would not let go. Resident #1's service plan calls for facility staff to speak to Resident #1 in a calm soft manner when he/she is exhibiting behaviors. The facility failed to ensure Resident #1's service plan was followed appropriately. This failure is a violation of Oregon Administrative Rules.,2,,,, +BO146533,50R281,RCF,3/10/2014,"Resident #1 had documented behaviors of combativeness toward staff and refused care frequently; however there were no updates to his/her care plan directing care staff for interventions. Resident #1 had become combative, hit Reported Perpetrator 2 (RP2) and RP2 held Resident #1's hands down. The facility failed to intervene and implement interventions regarding Resident #1's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,, +RD152866,50R281,RCF,8/28/2015,"The facility failed to provide a safe and secure environment. Resident #1 eloped from the facility through the garage door. Video footage time stamped about 2:49am; however he/she was not discovered missing from his/her room until approximately 5:15am. Resident #1 was found outside with injuries, was transported to the hospital and was diagnosed with a sprained arm, a brain bleed and required numerous stitches above his/her right eye. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BO151864,50R281,RCF,6/19/2015,"Resident #1 was found in Resident #2's room, standing over Resident #2 who was in his/her bed. Both residents had skin injuries. Resident #1 was care planned as having verbal and/or physically aggressive and required constant supervision for safety. The facility failed to ensure his/her care plan and failed to implement effective interventions. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +BO153288,50R281,RCF,8/4/2015,The facility failed to administer Resident #1 his/her medication as ordered. He/she did not suffer any observable adverse reaction. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO153867,50R281,RCF,10/3/2015,"The facility failed to implement interventions and care plan appropriately regarding Resident #1's behaviors to ensure resident safety. Resident #1 and Resident #2had an altercation on 10/3/15 and again on 10/9/15. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH116896,50R282,RCF,4/1/2011,"It was determined that a Facility staff member, Reported Perpetrator #2 (RP2) had been signing out medications for which he/she was not administering to residents. It was discovered due to RP2 allegedly administering medications to residents when he/she did not have the key to access the medications. RP2 was terminated from employment.",2,0,Not Substantiated,Substantiated,Financial abuse +BH148653,50R282,RCF,5/10/2013,"Resident #1, Resident #2, Resident #3, and Resident #4 reported money was missing between 7/21/13 - 7/25/13 totaling approximately $300. An unknown individual is responsible for the theft of money and is considered financial exploitation. The facility failed to ensure a safe environment to protect residents from theft. The failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BF104123,50R283,RCF,4/25/2010,"Resident #2 had a history of being protective of her/his room. The facility placed Resident #2 in a room that connects to a common bathroom. Resident #2 slammed the bathroom door when Resident #1 attempted to enter her/his room resulting in Resident #1's fingers to be smashed. The facility failed to adequately address Resident #2's behavior resulting in minor harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH120521B,50R283,RCF,7/3/2012,RP2 administered another resident's medication to Resident #2. Appropriate persons were notified and Resident #2 was monitored with no observable negative effects as a result of the medication error. The facility failed to ensure medication was administered as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH148506B,50R283,RCF,8/29/2014,Resident #1 resided in a secure facility due to her/his diagnosis of dementia. The facility sent Resident #1 unsupervised in a taxi cab after experiencing a medical condition. The facility failed to appropriately supervise Resident #1 while she/he was outside of the facility resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH148499,50R283,RCF,9/8/2014,"Resident #2 had a history of wandering and engaging in altercations with other residents. On September 2, 2014 facility requested a pyschological evaluation and a short term service plan was put in place on September 4, 2014 to require constant one on one care around the clock until otherwise noted. The following day, Resident #2 experienced a hip fractured after engaging in an unwitnessed altercation with another resident. The facility failed to adequately monitor Resident #2 as care planned resulting in moderate harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +BH159824,50R283,RCF,12/28/2014,Resident #1 resided in a secure memory care facility with a history of exit seeking. The facility failed to appropriately monitor and ensure a safe environment resulting in Resident #1_x001A_s elopement. Resident #1 was observed across the street from the facility and was returned without harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH151460,50R283,RCF,4/7/2015,"The facility failed to adequately monitor Resident #1's aggressive behavior resulting in a physical altercation with Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +BH164716,50R283,RCF,2/14/2016,"Witness #2 and Witness #3 were assisting RV1 with putting on his/her pajamas on or about February 14, 2016 when RV1 became combative by striking out and biting. RV1 left his/her bedroom, went to the common area of the facility and was involved in an altercation with RV2. The facility's failure to provide a safe environment is a violation of the Oregon Administrative Rules.",2,,,, +NB121821,50R285,RCF,12/6/2012,Resident #1 and RP2 were engaged in a verbal altercation. Witness testimony revealed RP2 was verbally inappropriate when responding to Resident #1's comments. The facility failed to ensure Resident #1's dignity and respect and is a violation of Oregon Administrative Rules.,2,0,,, +NB132144,50R285,RCF,1/16/2013,Resident #1_x001A_s medications were not administered as ordered the week of 1/14/13 thru 1/18/13 according to the Medical Administration Record (MAR). The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB133293A,50R285,RCF,5/22/2013,Resident #1 fell from his/her bed and was unable to call facility staff for help because he/she did not have a call light available. The fall resulted in a bruised knee. Resident #1 called his/her family member by telephone to alert facility staff of the fall. The facility failed to ensure Resident #1 had a call light available for assistance. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB148169,50R285,RCF,8/17/2014,"Resident #2 had a diagnosis of dementia with a history of aggressive behavior and quick to anger. On or about August 17, 2014, Resident #2 physically attacked Resident #1 in her/his room shortly after a verbal altercation in the dining room. The facility failed to adequately monitor Resident #2 resulting in Resident #1 being transported to the hospital for treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NB146847B,50R285,RCF,4/22/2014,Complainant reported that Resident #1's call light was not working. Investigation revealed that the call light was not working properly and the facility replaced the call light system. The facility failed to maintain a functional call light system resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +NB150593,50R285,RCF,3/16/2015,"Resident #1 had documented behaviors related to self harm and required supervision while smoking. On or about March 16, 2015, Resident #1 fell off the facility's deck while smoking unsupervised and sustained cuts and scrapes. The facility failed to monitor Resident #1 as care planned resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB116560,50R287,RCF,3/17/2011,"Reported Perpetrator 2 (RP2) failed to administer narcotic medication as ordered to Resident #1, Resident #2, and Resident #3; and diverted some of Resident #3's narcotic medications to him/herself.",2,0,Not Substantiated,Substantiated,Financial abuse +HB117449,50R287,RCF,7/14/2011,Resident #1 was administered his/her medication on 7/6/11; however it was discontinued on 7/5/11.,2,0,,, +HB129750,50R287,RCF,4/11/2012,"Resident #1 was known to intrude on the personal space of others, but had no history of resident altercations. Resident #2 was sensitive to others intruding on his/her personal space and had a history of non-injury resident altercations. Resident #1 grabbed Resident's glasses and he/she grabbed and squeezed Resident #1's arms. Staff immediately intervened. The facility failed to provide a safe environment and violated Oregon Administrative Rules.",2,0,,, +HB120764A,50R287,RCF,8/6/2012,"The facility failed to adequately address behaviors and implement interventions, resulting in repeated resident to resident altercations. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HB120764B,50R287,RCF,8/6/2012,"The facility failed to adequately address behaviors and implement interventions, resulting in repeated resident to resident altercations. Resident #2 suffered a scratch and bruise. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO13133,50R287,RCF,10/3/2013,"The facility failed to provide an RN assessment for Resident #2 who had a significant change of condition. Resident #2 experienced a worsening of skin breakdown. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB133871,50R287,RCF,7/22/2013,"Resident #1 was injured and transferred to the hospital for treatment after falling out of his/her wheelchair in the facility van during an outing. Reported Perpetrator 2 (RP2) stated the facility did not train staff how to safely secure residents into their wheelchairs and van. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB147046,50R287,RCF,5/13/2014,"The facility failed to implement adequate interventions around Resident #1's and Resident #2's aggressive behaviors. During an altercation Resident #1 hit Resident #2 in the head causing Resident #2 to fall. This failures is a violation of Oregon Administrative Rules, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +PT116438,50R288,RCF,2/10/2011,Resident #1 was care planned for his/her entire body to be bathed by staff three times a week. A skin assessment dated 2/10/11 indicated an open sore on his/her toes. For approximately 8-11 days Resident #1 was not showered or had a skin assessment conducted resuling in worsening of his/her wound.,2,0,,,Neglect +PT116605,50R288,RCF,3/5/2011,"The facility failed to adequately care plan related to Resident #1_x001A_s falls and frequent behavior of getting out of bed, and failed to implement a nursing recommended intervention of a pressure alarm. Resident #1 fell and suffered a fractured hip. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +PT116725,50R288,RCF,3/7/2011,"The facility failed to have physician ordered medication available for approximately two days resulting in Resident #1 being transported to the hospital for treatment. + +The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +PT118441,50R288,RCF,11/9/2011,"The facility failed to ensure RP2 knew proper transfer technique resulting in Resident #1 receiving a bruise to her/his arm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility was apportioned abuse.",2,0,,,Neglect +PT133282,50R288,RCF,5/6/2013,"It was reported Resident #1 kept snacks in his/her room and the facility had an ongoing problem with ants. Resident #1's food was covered with ants and due to a medical condition, Resident #1 did not know not to eat the food. The facility had the problem treated but the ants returned and were in Resident #1's room. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.",2,0,,, +PT133249,50R288,RCF,4/28/2013,"Between January and April, 2013 there were hundreds of narcotic pain medications that were delivered to the facility but never made it to Residents #1 - #5. Facility staff signed for medications that were not administered, some E-Medication Administration Records did not match narcotic records and some records showed more medications given than were actually administered. Reported Perpetrator 2 was seen on video opening delivered narcotic medications but not putting them on the medication cart. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect and constitutes abuse. Reported Perpetrator 2 is responsible for taking medications, which is considered financial exploitation and constitutes abuse.",3,350,Substantiated,Substantiated,Neglect +PT146072,50R288,RCF,1/23/2014,"Resident #2 had a history of becoming aggressive towards other residents that wander into his/her room. Resident #1 had a history of becoming agitated when in his/her old room and being asked to leave. An altercation ensued after Resident #2 found Resident #1 in his/her room, which is Resident #1's old room, and both residents sustained injuries. The facility failed to monitor both residents as stipulated per their service plans. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +PT149374,50R288,RCF,11/2/2014,"The facility failed to ensure a safe environment and implement interventions for behaviors. The failures resulting in resident to resident altercations affecting Resident #1, Resident #2 and Resident #3. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +PT159917,50R288,RCF,1/7/2015,"Resident #3's behavioral medications were discontinued by his/her physician. Subsequently, he/she had altercations with Resident #1 on 12/24/14 and Resident #2 on 1/7/15. Resident #3 had no prior physical altercations prior to his/her medications being discontinued. The facility failed to monitor Resident #3 and timely implement interventions to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +PT150893,50R288,RCF,3/26/2015,"Resident #1 and Resident #2 had an altercation on 3/26/15 and again on 4/4/15, injuries included a skin tear and bruising, and hair pulling and pushed down to the couch. Resident #1 had a history of aggression. The facility failed to implement effective interventions regarding Resident #1's behaviors to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +PT152363,50R288,RCF,7/14/2015,"Resident #2 had a history of aggression toward residents. Resident #2 hit Resident #1 on the chin and hit Resident #3 on the top of the head. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +PT152480,50R288,RCF,5/1/2015,"Narcotic pain medications were discovered missing. There is not enough clear evidence to identify the individual responsible for the theft of narcotic pain medications. Therefore, an unknown perpetrator is responsible for the theft. The facility failed to provide a safe medication administration system and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +HM152560,50R288,RCF,7/20/2015,"Resident #1 and Resident #2 hit each other during a dispute over a blanket that resulted in bruising to Resident #2. Resident #1 had a history of aggression towards other residents. The facility failed to monitor Resident #1 and care plan and implement interventions regarding his/her behavior. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +PT153073,50R288,RCF,8/25/2015,"The facility failed to investigate a bruise of unknown origin on Resident #1. The facility failed to provide services to assist with bathing, hygiene, and toileting. Resident #1 did not receive services as needed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH147746,50R289,RCF,5/12/2014,Reported Perpetrator 2 (RP2) wrongfully borrowed $1000 from Resident #1 and Resident #2. RP2 is found responsible for financial abuse. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Financial abuse +OR0001026600,50R289,RCF,11/6/2015,,1,,N/A,Substantiated, +HB116105,50R290,RCF,1/11/2011,"A resident experienced a loss of his/her personal property when jewelry that the resident was wearing was found to be missing. The resident was not able to remove the jewelry his/her self. The Facility was not able to determine the cause of the missing jewelry, but did offer a monetary reward for its return.",2,0,,,Financial abuse +HB118284,50R290,RCF,10/22/2011,Staff reported Resident #1 missing a gold necklace from around her/his neck. Resident #1 has a condition related to memory loss and was unable to recall what happened to it. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown person was found responsible for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +HB118452A,50R290,RCF,11/10/2011,It was discovered that Resident #1_x001A_s narcotic medications were missing. The theft of narcotic medications resulted from actions of an unknown individual. The facility failed to provide a safe medication administration system resulting in the loss of Resident #1_x001A_s medication. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB118452B,50R290,RCF,11/10/2011,During the course of the investigation of missing medication it was discovered there were procedural errors of the medication management system that helped facilitate the theft of narcotics. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rule.,2,0,,, +HB132358,50R290,RCF,2/6/2013,Items from Resident #1_x001A_s room and cash from his/her wallet were coming up missing. Witness #2 had a camera installed in Resident #1_x001A_s room. The camera captured Reported Perpetrator 2 (RP2) stealing money from Resident #1_x001A_s wallet on three occasions. Law Enforcement arrested RP2. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB132606,50R290,RCF,3/4/2013,"On 3/4/13, Resident #1 had two falls. He/she began to communicate pain after the first fall. The facility continued to administer PRN pain medication. On 3/7/13 Resident #1 was crying out in pain during transfers and personal care. On 3/8/13 the facility sent Resident #1 to the hospital due to complaints of pain. Resident #1 had sustained a left hip fracture. The facility failed to properly assess Resident #1 for a change of condition and obtain timely medical treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB146996,50R290,RCF,5/6/2014,"Resident #1 eloped from the facility by exiting two secured doors and another door leading outside. He/she has a history of exit seeking. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB149258,50R290,RCF,11/17/2014,"Resident #2 grabbed ahold of Resident #1's wrists and would not let go. Resident #2 sustained scratches on his/her arms from Resident #1 trying to get away from him/her. Resident #2 had four incidents of aggressive behavior toward staff prior to this incident. The facility failed to implement interventions regarding Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB149487,50R290,RCF,12/5/2014,"Resident #1 sustained a fall in the facility courtyard that caused injury. He/she was walking unsupervised. Resident #1's service plan states he/she is to be monitored when out in the courtyard. Resident #1 was transported to the hospital. The facility failed to follow Resident #1's service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB150835,50R290,RCF,4/7/2015,"RV1 and RV2 were memory impaired residents who resided in the secured unit of the facility. RV1 had a past history of altercations with other residents due to RV1 claiming property that did not belong to him/her. RV1 has a history of fluctuating moods with negative behaviors toward other residents including yelling, agitation and resisting care. On April 4, 2015 RV1 was agitated and grabbing items that did not belong to him/her such as RV2's purse. The facility intervened and RV1 became agitated. Later in the day on April 4, 2015, RV1 grabbed RV2's walker resulting in RV2 suffering a fall. RV2 experienced pain to the left side of his/her head and leg and was transported to the hospital. The facility failed to appropriately monitor and intervene resulting in RV2 suffering an injury and hospitalization. The facility's failures are a violation of resident rights and are considered neglect of care and constitute abuse.",2,,,,Neglect +HB150906,50R290,RCF,4/13/2015,Resident #1 sustained an injury to his/her left little finger from an unknown cause. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB150990,50R290,RCF,4/20/2015,"During a short period of time Resident #1 was involved in an altercation with Resident #4 and Resident #2. Resident #1 was also found fondling Resident #3's genitals while he/she slept in the common area. The facility failed to follow Resident #1's service plan regarding keeping Resident #1 away from other residents and care plan appropriately for his/her behaviors. The facility also failed to provide appropriate staffing and training. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB152325,50R290,RCF,8/3/2015,"Resident #1 had a history of behaviors that included grabbing/touching of staff persons and saying inappropriate things that were of a sexual nature toward staff. Resident #1 was found in the common area fondling Resident #2's genitals. Resident #2 was tearful after the incident. The facility failed to provide a safe environment that resulted in Resident #2 being fondled by Resident #1. The facility also failed to appropriately care plan Resident #1 for his/her behaviors and follow care plan that was in place. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse.",3,300,,,Sexual abuse +HB152791,50R290,RCF,9/11/2015,"Resident #1 and Resident #2 had a previous altercation when Resident #2 entered Resident #1's room. Care Plan updates were made to keep residents separated. A second incident of Resident #2 entering Resident #1's room occurred and Resident #1 sustained skin tears. The facility failed to follow Resident #1 and Resident #2's care plans. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB152933,50R290,RCF,9/25/2015,"Resident #1 was a high fall risk. Resident #1 had a non-witnessed injury fall on 9/14/15, this fall was not reported to Adult Protective Services (APS) nor were any updates added to his/her service plan. Resident #1 fell again on 9/24/15 resulting in a fractured hip and wrist. The facility failed to update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF104888,50R292,RCF,7/26/2010,"The facility failed to provide lock boxes in all residents rooms. At least three residents had rings taken from their respective rooms, two of which did not have lockable storage space provided by the facility. There were multiple suspects, none of which could be directly linked. The facility failed to provide a safe environment resulting in the loss of residents' property. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Financial abuse +KF116511,50R292,RCF,3/13/2011,"The Facility failed to follow the care plan for Resident #1 with respect to providing incontinence care and assistance with putting the resident to bed. During rounds it was discovered that Resident #1 had suffered a fall in his/her room, sustaining injury. The resident was transported to the hospital in his/her daytime clothing and he/she was incontinent.",3,300,,,Neglect +KF132283A,50R292,RCF,1/27/2013,"Resident #1 had multiple falls with the last fall resulting in a fractured hip and surgery. There were no updates to Resident #1's service plan regarding fall interventions, no quarterly reviews or evaluations and no changes to his/her service plan since move-in in June 2012. The facility failed to adequately update Resident #1's service plan to address fall interventions and evaluate him/her. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF132283B,50R292,RCF,1/27/2013,"Bed rails were installed by Resident #1_x001A_s family. The facility was aware the bed rails had been installed and did not obtain an MD order, update the service plan or assess Resident #1 for the use of bed rails. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF134946,50R292,RCF,11/2/2013,"Resident #1 fell in her/his room and suffered a skin injury that required transportation to the hospital for treatment. Witness testimony and facility documentation revealed multiple falls with injuries. Resident #1 also had documented incidents regarding decline in cognition. Resident #1's care plan failed to adequately address these significant changes of conditions. The facility failed to assess and intervene resulting in harm and the potential for serious harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF145555,50R292,RCF,1/1/2014,"Resident #1 experienced recent falls, reported being dizzy & weak and was transported to the hospital. Upon return to the facility, Resident #1 fell outside of the facility entrance and was transported to the hospital for comminuted nasal fracture. Video feed showed no mobility assistance for Resident #1 upon return to the facility until after the fall occurred. The facility failed to appropriately care plan for falls after Resident #1 experienced a significant change of condition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF135096,50R292,RCF,11/18/2013,"Resident #1 experienced a fall with injury that required transportation to the hospital for treatment. Witness testimony and facility documentation revealed Resident #1 had an increased decline in cognition and frequently forgot to call for assistance and to utilize her/his walker. The facility failed to adequately care plan for falls resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF146200,50R292,RCF,2/24/2014,"Complainant reported the facility failed to follow Resident #1's care plan resulting in falls with injury. Facility documentation identified Resident #1 as a high fall risk and care planned to assist with dressing and toileting reminders. Resident #1 experienced two falls, one while dressing and the other while returning from toileting at night. Witness testimony revealed that the staff were not assisting the resident as care planned. The facility failed to ensure the service plan was followed resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +KF147860,50R292,RCF,7/22/2014,"Resident #1 required two person assistance for most activities of daily living including being rotated three to four times a shift and checked on hourly. Witness testimony and facility documentation revealed Resident #1 was not being checked on or cared for as care planned including rotating, transferring or providing meals on one known occasion. Resident #1 sustained multiple pressure soars. The facility failed to ensure adequate, qualified staff to meet the care needs for Resident #1. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF150518,50R292,RCF,3/10/2015,"Resident #1 had a prescription for continuous oxygen and care planned as needing medication administration assistance. The facility failed to adequately care plan and provide staff direction surrounding oxygen resulting in the resident not consistently receiving adequate oxygen as ordered. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF150361,50R292,RCF,2/20/2015,RP2 took an inappropriate digital photo of Resident #1 and shared it on a social network websight. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rights. RP2 was found responsible for emotional harm and constitutes abuse.,3,,Not Substantiated,Substantiated,Verbal/Mental abuse +KF151468,50R292,RCF,5/5/2015,"Resident #1 had a history of infection which caused confusion and falls. Facility documentation revealed Resident #1 began treatment related to an infection on May 1, 2015. On May 5, 2015, Resident #1 was found missing from her/his room and later found in an empty room unresponsive. The facility failed to adequately monitor Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF150140,50R292,RCF,2/4/2015,"The facility failed to adequately monitor and document checks after Resident #1 experienced a fall. Resident #1 was found several hours later on the floor. Resident #1 was transported to the hospital and admitted for treatment of a condition unrelated to the fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +OR0001024100,50R292,RCF,10/30/2015,,0,,Not Substantiated,Substantiated, +BH116074B,50R293,RCF,12/29/2010,"A Facility staff member, who was known to be short and not courteous to residents by his/her peers, was twice witness by his/her peers to provide incontinence care to Resident #2 in a manner that caused the resident to scream out in pain.",2,0,,,Neglect +BH120282,50R293,RCF,4/17/2012,Resident #1 was reported to have inappropriate sexual behaviors toward caregivers. His/her service plan was updated with this information. He/she denies the allegations. Resident #1 now feels he/she has become an emotional wreck due to the stigma. The facility failed to assure resident rights and protections. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH120752,50R293,RCF,7/23/2012,Resident #1 paged for assistance and was not happy with Reported Perpetrator 2_x001A_s (RP2) care and asked him/her to leave and send another caregiver. Resident #1 was left sitting on the side of the bed. It was 20 minutes before another caregiver responded. Resident #1 slid onto the floor. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO12131,50R293,RCF,11/8/2012,"The facility failed to ensure administrative oversight to ensure adequate resident care, services and overall administration of the facility to ensure reasonable precautions were taken against conditions that could threaten the health, safety and welfare of residents. The facility also failed to evaluate, develop appropriate interventions, monitor and provide and RN assessment for residents consistent with their needs. Resident #13 was at high risk for elopement from the building. Resident #1 did not receive timely medical treatment related to a fracture. Resident #1, #14 and #15 failed to be evaluated and monitored consistent with their needs related to falls and a skin condition. Resident #1 and #15 failed to be referred for a significant change of condition to the RN. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,1200,,,Neglect +CO13029,50R293,RCF,3/13/2013,"The findings of the Residential Care Facility Re-licensure Survey conducted March 12 - 13, 2013 determined that the Facility was not in substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility's noncompliance placed residents at harm and risk for serious harm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,0,,,Neglect +BH133341,50R293,RCF,5/22/2013,The facility failed to administer Resident #1_x001A_s medications according to physician_x001A_s orders. Resident #2 was not administered a prescribed narcotic medication. Resident #1 exhibited behavioral issues after the medication error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH150464,50R293,RCF,3/3/2015,"Resident #1 and Resident #2 had money go missing from their rooms. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +BH151395,50R293,RCF,5/18/2015,"Resident #1 had medication go missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH153478,50R293,RCF,9/6/2015,"Resident #1 had money go missing from his/her room. The money was taken by Reported Perpetrator #2, and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH153496,50R293,RCF,10/7/2015,"Residents #1, #3, and #4 had property go missing from their rooms. The money was taken by an Reported Perpetrator#2 and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH153545,50R293,RCF,10/6/2015,"The facility failed to adequately administer Resident #1's pain medication due to failing to re-order the medication. Resident #1 experienced increased pain symptoms as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BH153786,50R293,RCF,10/28/2014,"Resident #1 had a check go missing from his/her room. The check was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB117691,50R294,RCF,8/10/2011,Resident #1 had a valuable ring discovered missing from his/her room between 7/25/11 - 7/28/11. There were three people noted to be in his/her room on 7/27/11. An unknown individual was responsible for the loss of his/her property.,2,0,Not Substantiated,Substantiated,Financial abuse +GP116500,50R295,RCF,3/9/2011,The facility failed to provide a system that prevents theft or misuse of narcotic medications. Reported Perpetrator 2 misappropriated Resident #1's and Resident #2's narcotic medications.,2,0,Substantiated,Substantiated,Financial abuse +GP118763,50R295,RCF,12/22/2011,The card of 30 tabs of Resident #1's narcotic pain medications and a page from the narcotic log book were discovered missing between 12/22/11 and 12/23/11. Video recording show the actions of Reported Perpetrator 2 (RP2) stealing the narcotic medication card and the log; thus RP2 being responsible for the theft of Resident #1's medications.,2,0,Not Substantiated,Substantiated,Financial abuse +AS116440,50R296,RCF,3/1/2011,"The facility failed to provide oversight and monitoring resulted in worsening of Resident #1_x001A_s pubic area. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AS116645,50R296,RCF,3/15/2011,Resident #1 fell while RP2 was providing care to her/him. RP2 failed to document the incident and appropriately report it. The failure is a violation of OARs.,2,0,,, +AS116920,50R296,RCF,5/1/2011,The facility failed to assure resident rights resulting in the loss of dignity. The failure is a violation of OARs.,2,0,,, +CO12001,50R296,RCF,12/7/2011,The facility failed to provide effective administrative oversight regarding residentss quality of care and services as evidenced by the 26 citations. Please refer to the survey for specific details.,3,0,,,Neglect +AS118425,50R296,RCF,11/7/2011,"Resident #2 had a history of aggressive behaviors and care planned for staff to make sure Resident #2's door is locked so that residents cannot enter. On or about November 7, 2011 Resident #1 was found in Resident #2's room. Blood and hair were observed throughout the room and Resident #1 was transported to the hospital for treatment. The facility failed to follow Resident #2's care plan resulting in harm.",3,300,,,Neglect +AS128912,50R296,RCF,1/1/2012,"Resident #2 had a recent increased history of aggressive behavior and the facility failed to care plan resulting in a physical altercation that left scratches on Resident #1's face. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AS129654,50R296,RCF,3/30/2012,The facility failed to provide a safe environment resulting in the elopement of Resident #1. Resident #1 was able to exit the secured facility using an unlocked door that was being accessed by construction crews during a remodel. Resident was observed and retrieved without harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AS129440,50R296,RCF,3/8/2012,The facility failed to provide a safe environment resulting in the elopement of Resident #1. Resident #1 was able to exit through the unlocked courtyard gate. Staff retrieved Resident #1 right away without harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AS129342,50R296,RCF,2/26/2012,"Resident #1 required staff to clean her/his dentures and care plan indicated the resident resists denture care. On February 26, 2012, RP2 and RP3 held down Resident #1's hands to take out her/his dentures for routine cleaning after she/he became resistive. The facility failed to provide adequate direction to staff on how to deal with Resident #1's resistance to denture care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AS121874,50R296,RCF,12/9/2012,Resident #1 was observed to be walking with Reported Perpetrator 2 (RP2) down the hall. There were conflicting witness reports in regard to whether Resident #1 was pushed by RP2 or if he/she fell. No injuries were sustained. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AS132293,50R296,RCF,1/26/2013,Reported Perpetrator 2 (RP2) gave Resident #1 another resident's medication. Resident #1 vomited and was transported to the hospital for an assessment and returned to the facility. RP2 was found responsible for abuse (neglect of care). The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Neglect +AS134063,50R296,RCF,8/6/2013,"The facility failed to update Resident #1 and Resident #2's service plans despite repeated incidents of aggressive behavior towards each other. This failure is considered neglect of care, constitutes abuse, and violates Oregon Administrative Rules.",2,,,,Neglect +AS147580,50R296,RCF,6/22/2014,"Resident #1 and Resident #2 had medication taken from the facility med room. Reported Perpetrator #2 was suspected to have taken the medication however it remains unclear exactly who took the medication. Therefore, an unknown individual was responsible for taking the medication which is considered financial exploitation and constitutes abuse. The facility failed to protect both residents medication from theft. This failure was a violation of Oregon administrative rules.",2,,Not Substantiated,Substantiated,Financial abuse +AS133008A,50R296,RCF,4/17/2013,The facility failed to maintain a minimum of two caregivers for the scheduled and unscheduled needs of the residents. This failure is a violation of Oregon Administrative Rules.,2,,,, +AS133008B,50R296,RCF,4/17/2013,"The facility failed to follow Resident #1's care plan requiring night time checks for incontinent care. Resident #1 found in a wet bed with soaked mattress in the morning. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +AS150032,50R296,RCF,1/22/2015,"Reported Perpetrator #2 (RP2) slapped resident #1 twice. RP2 is responsible for physical abuse. The facility failed to protect Resident #1 from rough treatment, which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +AS151853,50R296,RCF,6/18/2015,"Resident #1 has a condition related to memory loss and resided in a secure memory care community. On or about June 18, 2015, Resident #1 was discovered outside of the building and was returned unharmed. The facility failed to ensure a safe environment resulting in the potential for harm.",2,,,, +DA104289,50R297,RCF,5/11/2010,"The facility failed to provide a safe medication administration system resulting in the loss of narcotic medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Financial abuse +DA116937B,50R297,RCF,4/28/2011,"Resident #1 was care planned to receive PRN medication when he/she expressed agitated behaviors. For approximately two months, the PRN was not administered despite frequent agitation that created significant challenges to providing appropriate care for him/her. When the order was changed to a scheduled medication, his/her behaviors improved.",2,0,,,Neglect +DA118038,50R297,RCF,9/20/2011,Resident #1 was agitated and exit seeking. The facility failed to appropriately monitor resulting in successful elopement from the facility.,2,0,,, +DA118153,50R297,RCF,9/29/2011,"Resident #1 had a history of seeking out physical contact from others requiring redirection and supervision, and he/she had impaired cognition. While on a facility outing, Resident #1 was seated next to another resident of the opposite gender from the Assisted Living part of the facility, where inappropriate touching occurred.",2,0,,, +DA147803B,50R297,RCF,5/29/2014,The facility failed to ensure residents were treated with respect and dignity by actions of Reported Perpetrator 2 and Reported Perpetrator 3. The failure is a violation of Oregon Administrative Rules.,2,,,, +DA150714,50R297,RCF,3/25/2015,Resident #1 was a known fall risk and his/her care plan instructed staff to stand-by assist with all transfers and ambulation to mitigate falls. Reported Perpetrator 2 (RP2) did not provide stand-by assist resulting in Resident #1 falling and suffered injuries requiring hospitalization. RP2's actions are considered neglect of care and constitutes abuse. The facility failed to ensure Resident #1's care plan was followed and violates Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Neglect +DA151800,50R297,RCF,8/22/2014,"It was discovered that there was several discrepancies involving missing narcotics, primarily Morphine. Staff were drug screened and tested negative. Liquid narcotic counts being ""slightly off"" was an accepted practice with the previous company. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.",2,,,, +DA152833,50R297,RCF,9/13/2015,"Resident #1 slapped Resident #2 on the face. Resident #1 had known history of slapping other residents prior to this incident. The facility failed to implement and care plan interventions regarding his/her behavior. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +MV150938,50R298,RCF,4/9/2015,"The facility failed to adequately follow Resident #1_x001A_s care plan for stand by assistance. Resident #1 was left alone in his/her bathroom, and fell requiring hospital care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV117656,50R300,RCF,8/4/2011,RP2 failed did not place foot rests on Resident #1's wheelchair as directed on her/his care plan resulting in the resident falling and sustaining injury. The facility failed to ensure care plan was followed resulting in minor harm. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Neglect +BC118236,50R301,RCF,10/16/2011,"Resident #1 was found in the kitchen at approximately 2:00 AM screaming _x001A_it hurts, it hurts_x001A_ with her/his hands over her/his mouth. An open can later identified as highly corrosive liquid dishwashing soap was found on the kitchen counter next to the resident. Resident #1 was transported to the hospital and died two days later. The facility failed to provide a safe environment resulting in serious injury and contributed to the death of Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,2500,,,Neglect +BC118449,50R301,RCF,11/12/2011,"Failed to address Resident #1's aggressive behavior resulting in negative behaivor affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC133045A,50R301,RCF,3/19/2013,Resident #1's oral care was not correctly checked off on the ADL sheet by caregivers. Resident #1 had a decreased appetite and weight loss. Resident #2 experienced poor dental care. The facility failed to provide appropriate care for Resident #1 and Resident #2. The failures are a violation of Oregon Administrative Rules.,2,0,,, +BC133045C,50R301,RCF,3/19/2013,Resident #2 was sent to his/her physician's appointment without his/her hip protectors or 4WW. The facility failed to follow Resident #2's care plan. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC133045B,50R301,RCF,3/19/2013,"Resident #1 experienced a decreased appetite and weight loss and was not assessed for a change of condition. He/she lost twenty pounds during a twenty day period. Reported Perpetrator 2 (RP2) failed to intervene and attain medical care for Resident #1 or report his/her change of condition to his/her physician. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to assure Resident #2's care plan was followed for oral care and failed to assure Resident #1 and Resident #2 were provided appropriate care resulting in harm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,Substantiated,Substantiated,Neglect +BC133566,50R301,RCF,6/1/2013,Reported Perpetrator 2 (RP2) was witnessed pushing Resident #1 backward and cursing at him/her. Resident #1 fell backward and was sent to the hospital. Resident #1 sustained a broken wrist. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Physical Abuse +BC145571,50R301,RCF,12/27/2013,Resident #1 had a history of calling facility staff names. Resident #1 is care planned to redirect when resistive to care. All staff are trained on how to work with difficult behaviors. Reported Perpetrator 2 (RP2) made derogatory statements twice when addressing Resident #1. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +BC159804,50R301,RCF,1/2/2015,"Resident #1 was agitated and hitting care givers as they tried to provide care. Reported Perpetrator 2 (RP2) was assisting with care also. RP2 was witnessed slapping Resident #1. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment and assure Resident #1's resident rights. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Neglect +BC154005,50R301,RCF,12/15/2015,"The facility failed to assess and intervene in a timely manner after Resident #1 fell on 12/16/15. He/she was transported to the hospital on 12/19/15 and diagnosed with a hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AL105838,50R302,RCF,9/23/2010,"On 9/23/10, Resident #1 attacked Resident #2 in her/his room. Resident #1 had two recent incidents of aggressive behavior. There was no documented evaluation, assessment or interventions to address Resident #1's increased aggressive behaviors to prevent future incidents. The facility failed to address Resident #1's increase agitated and aggressive behavior resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO11024,50R302,RCF,1/11/2011,"Based on interview and record review it was determined the facility failed to follow orders for Resident 3 resulting in an infection to her/his foot. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL118412,50R302,RCF,9/19/2011,"Resident #1 was identified as a fall risk and required constant reminders to use her/his four wheel walker. Resident #1 was found on or about September 19, 2011 without her/his walker. The facility failed to ensure Resident #1's Service Plan was followed resulting in the potential for harm.",2,,,, +AL117753B,50R302,RCF,8/15/2011,The facility was monitoring Resident #1_x001A_s intake of fluids and output. Resident #1 was admitted to the emergency room for treatment. The facility failed to assure proper hydration for Resident #1. The failure is a violation of Oregon Administrative Rule.,2,0,,, +AL146817,50R302,RCF,10/20/2013,Resident #1 and Resident #2 were involved in an altercation. Neither resident sustained any injuries. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL147812,50R302,RCF,1/17/2014,Reported Perpetrator 2 (RP2) was witnessed being rough with Resident #1 while providing care. RP2 was witnessed striking Resident #1's forearm in response to Resident #1 striking RP2. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +CO15198,50R302,RCF,9/23/2015,"A re-licensure survey completed on September 3, 2015, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to ensure compliance with health care services regulations. The facility also failed to ensure a Registered Nurse assessed and documented findings for five residents. Resident #4 and Resident #7 had ongoing, significant weight loss. Resident #6 experienced repeated skin breakdown. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,900,,,Neglect +ES117966B,50R304,RCF,6/6/2011,"The facility failed to provide clear direction on how to provide proper bandage care. Reported Perpetrator 3 (RP2) used an improper technique to remove Resident #1's bandage causing him/her unnecessary pain and the wound to reopen. Resident #1 said ""ow"" and RP3 continued with the improper technique.",2,0,Substantiated,Substantiated,Neglect +ES121440,50R304,RCF,10/25/2012,Resident #2 struck Resident #1. Resident #2 had been experiencing increased agitation and aggression two weeks prior to this incident. Resident #2 had struck another resident prior to this incident and it was not reported to APS. Resident #2_x001A_s care plan was not updated regarding his/her agitation and aggression. There was also no information regarding interventions. The facility failed to update Resident #1_x001A_s care plan and report a resident to resident altercation. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES133073,50R304,RCF,4/24/2013,Reported Perpetrator 2 (RP2) took a picture of him/her self and Resident #1. This picture was then posted on a social media site. The facility failed to assure Resident #1_x001A_s rights and provide appropriate training to RP2. The failures are a violation of Oregon Administrative Rules.,2,0,,, +ES147509,50R304,RCF,6/23/2014,The facility documented that Resident #1 was not doing well on several occasions and that the family should take him/her to urgent care. The facility failed to timely coordinate health services for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES151787,50R304,RCF,7/1/2015,Resident #1's debit card was kept at the facility. Reported Perpetrator 2 (RP2) had access to the card and was to withdraw payments to the facility. Resident #1's money was withdrawn and payment was not made to the facility. RP2 admitted to using the debit card to withdraw money for his/her benefit. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES151805,50R304,RCF,6/1/2015,Reported Perpetrator 2 (RP2) made cash withdrawals from Resident #1's account in the amount of $500.00 and $700.00. The facility had assumed responsibility to manage Resident #1's accounts. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES152788,50R304,RCF,5/1/2015,"Reported Perpetrator 2 (RP2) cashed a check that belonged to Resident #1 in the amount of $1,310.48. Resident #1 was not capable of managing their own finances. There was no indication the money was used for Resident #1's benefit. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +CO11008,50R305,RCF,1/10/2011,,0,0,,, +BH116914A,50R305,RCF,5/2/2011,Reported Perpetrator 2 did not appropriately transfer Resident #1 making it uncomfortable to him/her.,2,0,,, +BH117157B,50R305,RCF,6/1/2011,Narcotic medications prescribed for Resident #1 went missing from the facility.,2,0,,,Financial abuse +CO11105,50R305,RCF,8/19/2011,"The preliminary findings of the Residential Care Facility Re-licensure Survey conducted August 16 - 18, 2011, determined that the Facility was not in substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility_x001A_s noncompliance placed residents at harm and risk for serious harm. The failures are a violation of resident rights, are considered neglect and constitute abuse.",3,0,,,Neglect +BH129436,50R305,RCF,3/2/2012,"Resident #1 had physician's orders for self-medicating and had narcotic medications in his/her room. Narcotic medications were discovered missing on 3/3/12. An unknown individual is responsible for the theft of narcotic medications which constitutes abuse. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. + + + +The Notification of Findings was completed at a later date due to the extended period of time between the incident date and processing by the Department.",2,0,Not Substantiated,Substantiated,Financial abuse +BH117620,50R305,RCF,8/1/2011,Reported Perpetrator 2 (RP2) inappropriately spoke to Resident #1 causing him/her to be upset. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,,Verbal/Mental abuse +BH121859,50R305,RCF,10/14/2012,"On 10/14/12, Reported Perpetrator 2 (RP2) put his/her hand in front of Resident #1's mouth in an attempt to quiet him/her. Resident #1 did not have any observable negative outcome. The facility failed to ensure Resident #1 was treated with respect and dignity. The facility failed to report this incident timely to the local Adult and Protective Services office. The failures are a violation of Oregon Administrative Rules.",2,0,,, +BH133245,50R305,RCF,5/16/2013,"The facility failed to follow Resident #1's care plan for clipping his/her toenails. Resident #1's nails were found to be long and painful. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH133772,50R305,RCF,7/1/2013,"Resident #1 had a physician's order to self-administer medications. Resident #1 said there was about a two month period when he/she did not have a lot of pain and did not use the medications. Resident #1 said when he/she had some leg pain and wanted to take some medications, there were only two pills left and reported someone took the medications from his/her room. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the narcotics, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BH133773,50R305,RCF,7/2/2013,"Facility staff stated Resident #1 and #2's rent checks were in a drawer in the medication room and went missing. Facility surveillance cameras revealed Reported Perpetrator 2 (RP2) taking something from the drawer in the medication room. W1 stated RP2 admitted to taking the checks. RP2 is responsible for theft, which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BH134287,50R305,RCF,8/26/2013,"The facility failed to protect residents from inappropriate sexual contact of actions by Resident #1. On 8/23/13, he/she was care planned with interventions for inappropriate sexual behavior. Further incidents occurred 8/24, 8/25 and 8/26; however no new interventions were implemented. The facility failed to provide a safe environment resulting in Resident #1 having inappropriate sexual contact with Resident #2 and Resident #3. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse and constitutes abuse.",3,2500,,,Sexual abuse +CO13129,50R305,RCF,11/7/2013,"The Facility failed to provide effective administration oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed November 7, 2013.",4,,,,Neglect +BH134788,50R305,RCF,9/30/2013,"The facility failed to ensure Resident #1's prescribed narcotic medication was available to be administered as ordered. Resident #1 suffered pain from missing 9 doses of the medication. The facility also failed to report this incident to the local APD office. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +BH135146,50R305,RCF,11/4/2013,"While providing care to Resident #1, Reported Perpetrator 2 (RP2) clapped Resident #1's shoes together, either in front of or next to, his/her face, startling Resident #1. The facility failed to ensure Resident #1 was treated with dignity and respect and is a violation of Oregon Administrative Rules.",2,,,, +BH135430,50R305,RCF,12/14/2013,"On 12/14/13, Resident #1's foot became twisted under his/her wheelchair causing an ankle fracture. The facility failed to properly care plan to provide a clear direction and description regarding the use of wheelchair footrests for Resident #1. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +This incident warrants a civil penalty; however due to the fact that the facility is currently in a license condition status (#RCFCD13-008) a civil penalty will not be issued.",3,,,,Neglect +BH146153,50R305,RCF,2/2/2014,"The facility failed to timely address Resident #1's pain to administer medication to reduce his/her pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH150017,50R305,RCF,1/11/2015,Reported Perpetrator 2 (RP2) and Resident #1 had a verbal altercation and RP2 called Resident #1 a derogatory name. RP2's actions are considered verbal abuse. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +BH149617,50R305,RCF,12/17/2014,The facility failed to ensure staff conducted proper night time checks on Resident #1 and failed to ensure gates had properly functioning locks. Resident #1 had eloped from the building. The facilities failures exposed Resident #1 to potential harm and failures are violations of Oregon Administrative Rules.,2,,,, +BH150375,50R305,RCF,1/25/2015,"Reported Perpetrator 2 (RP2) was observed agitating Resident #1, Resident #2 and Resident #3 on many occasions, and RP2 was also observed filming their reactions and showing other staff. RP2's actions are considered verbal and emotional abuse. The facility failed to protect residents from abuse and to ensure residents were treated with respect and dignity and is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +BH150889,50R305,RCF,1/20/2015,"Resident #1 and Resident #2 have cognitive deficits. They had an altercation, with no injuries but Resident #2 was shaken and crying afterwards. The facility failed to provide a safe environment.",2,,,, +BH150688,50R305,RCF,3/23/2015,"The facility failed to ensure staff followed Resident #1's care plan for incontinence care. Resident #1 sustained an open sore that required wound care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH152131,50R305,RCF,7/13/2015,Resident #1's care plan was not followed. He/she had a fall without injury. The facility's failures is a violation of resident rights and Oregon Administrative Rules.,2,,,, +BH153648A,50R305,RCF,11/12/2015,"Resident #1 was physically aggressive with Resident #2 and Resident #3. Resident #1 had history of physical aggression towards other residents. The facility failed to ensure a safe environment free from resident to resident altercations. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH153648B,50R305,RCF,11/12/2015,The facility failed to ensure a safe medication administration system to ensure Resident #1's medication was reordered to administer as ordered. He/she went without his/her medications for 5 doses. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +BH153649A,50R305,RCF,11/13/2015,"Resident #1 was physically aggressive with Resident #2. Resident #1 had history of physical aggression towards other residents. The facility failed to ensure a safe environment free from resident to resident altercations. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH153649B,50R305,RCF,11/13/2015,The facility failed to ensure a safe medication administration system to ensure Resident #1's medication was reordered to administer as ordered. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +BH147965,50R305,RCF,7/23/2014,"On 7/23/14, Reported Perpetrator 2 (RP2) was providing personal care to Resident #1 and was being rough when Resident #1 expressed discomfort but RP2 continued with care. Resident #1 was found to have skin injury as a result. RP2's actions are considered physical abuse. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +BH153944A,50R305,RCF,4/13/2012,"On or about 4/13/12, Resident #1 discovered approximately $50-$90 dollars missing from his/her lock box in his/her room that appeared to have been tampered with. An unknown individual is found responsible for the theft of Resident #1's money, which constitutes financial exploitation. The facility failed to ensure a safe environment to protect from theft. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH149665,50R305,RCF,12/22/2014,"Resident #1 was care planned to be checked for toileting every two hours during the night. On 12/22/14, he/she was checked about 2:00am, but not again until about 5:00am, more than two hours. Resident #1 was found to have a swollen eye that was starting to purple. The facility failed to follow his/her care and failed to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH164299,50R305,RCF,1/14/2016,"The facility failed to ensure Resident #2's care plan was followed to monitor him/her and remind of his/her room number; and failed to implement other interventions regarding his/her behavior and inability to understand. Resident #2 hit Resident #1, but suffered no injuries. The facilities failures are a violation of resident rights and Oregon Administrative Rules.",2,,,, +BH164257,50R305,RCF,1/9/2016,The facility failed to follow Resident #1's care plan to perform and document 30 minute checks while sleeping. Resident #1 fell out of bed twice in the early morning of 1/9/16. The failures are a violation of resident rights and Oregon Administrative Rules.,2,,,, +BH164415B,50R305,RCF,6/9/2014,"On or about 5/28/14, approximately 28-30 tablet narcotic pain medication was taken from Resident #1's apartment. The investigation did not reveal enough evidence to identify a named individual; therefor an unknown individual is responsible for the theft of medications, which constitutes abuse. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH150306,50R305,RCF,2/14/2015,"The facility failed to follow Resident #1's care plan to ensure 30 minute checks were conducted and documented; and failed to properly plan care due to rolling out of his/her bed. Resident #1 was found on the floor next to his/her bed with injuries to his/her right eye and right knee. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +OR0001005400,50R305,RCF,9/18/2015,,0,,Not Substantiated,Substantiated, +OR0001005401,50R305,RCF,9/18/2015,,0,,Not Substantiated,Substantiated, +OR0001052500,50R305,RCF,1/20/2016,,0,,Not Substantiated,Substantiated, +CO14106,50R306,RCF,4/29/2014,"The facility failed to ensure physician orders were obtained or carried out as prescribed resulting in Resident #2 experiencing uncontrolled pain. The facility failed to post an exit code near an outdoor gate on which there was a keypad locking mechanism, creating a risk for harm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +KF159960,50R306,RCF,1/17/2015,"Resident #1 had aggressive behaviors and had been witnessed taking other residents' plates or cups. Resident #1 attempted to take an item from Resident #2 by grabbing Resident #2's wrist. Resident #2 was visually upset and crying and experienced a discoloration to his/her wrist. The facility failed to care plan and implement interventions regarding Resident #1's behavior making it an unsafe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF150280,50R306,RCF,2/15/2015,"Resident #1 was new to the facility and prior to moving into the facility, he/she had a sitter to keep him/her from getting out of bed without assistance. The facility provided a tabs alarm and pressure pad to prevent falls. Staff were not always able to reach him/her timely. On 2/15/15, Resident #1 experienced a fall resulting in a fractured femur. There was only one staff member on duty at the time of the fall, and there were approximately three other residents with high nighttime care needs. The facility failed to ensure adequate staffing to provide care and a safe environment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF151375,50R306,RCF,5/23/2015,"The facility failed to appropriately care plan and implement interventions regarding Resident #1's behaviors to provide a safe environment. Resident #1 and Resident #2 had an altercation. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF151753,50R306,RCF,6/26/2015,"The facility failed to adequately care plan and implement interventions and follow PRN medication instructions regarding Resident #1's behaviors. Resident #1 had behaviors of aggression towards staff and residents. Resident #1 hit Resident #2 in an aggressive manner resulting in bruising on Resident #2. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF152222,50R306,RCF,6/25/2015,"The facility failed to assess, intervene and monitor Resident #1's change of condition. Resident #1 fell and suffered a fractured hip. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF152190,50R306,RCF,7/23/2015,"Resident #1 became weak and lethargic after 6/23/15, and between 6/17/15 and 7/22/15, Resident #1 suffered a severe loss of approximately 31 pounds. He/she had poor cognition and was unable to feed him/herself. The facility failed to feed Resident #1 appropriately, failed to follow physician and Hospice orders regarding nutritional requirements, and failed to follow physician orders regarding medication changes. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +KF152971,50R306,RCF,9/23/2015,"The facility failed to intervene, monitor, and properly plan care related to Resident #1_x001A_s declining health and frequent falls. Resident #1 suffered injuries from falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +OR0001012000,50R306,RCF,10/5/2015,,0,,Not Substantiated,Substantiated, +MS132418,50R307,RCF,2/14/2013,"Resident #1 eloped from the facility on three separate occasions. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a know elopement risk. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS151737,50R307,RCF,6/10/2015,"The facility failed to adequately plan interventions in relation to Resident #1_x001A_s fall risk. Resident #1 had suffered a previous hip fracture and was known to attempt to transfer him/herself despite requiring assistance with transfers. Resident #1 fell again after attempting to ambulate to his/her bathroom, and sustained another hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH135048,50R308,RCF,11/10/2013,"Resident #1 was a fall risk and was service planned for stand-by assistance when toileting. Reported Perpetrator 2 (RP2) was not aware of the service plan and left Resident #1 alone in the bathroom for privacy. Resident #1 fell sustaining a head injury requiring emergency room treatment. The facility failed to follow Resident #1's service plan and assure proper training to staff. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH134493B,50R308,RCF,9/19/2013,The facility failed to ensure that an allegation of abuse was reported to the local APS office. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC116782A,50R309,RCF,3/18/2011,The facility failed to ensure that the same staff person setting up or pouring the medications also documented and administered the medication to the residents of the facility.,1,0,,, +BC116782B,50R309,RCF,3/18/2011,The facility failed to ensure adequate professional oversight of the medication and treatment systems regarding delegation responsibilities.,2,0,,, +BC116782C,50R309,RCF,3/18/2011,Residents were exposed to facility staff confrontations.,2,0,,, +MV120184,50R310,RCF,5/29/2012,"The facility failed to provide a safe environment regarding Resident #1_x001A_s multiple falls and increased behaviors. On 5/29/12, Resident #1 fell backward and hit his/her head on the floor and suffered a cranial fracture, and passed away due to the injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,2500,,,Neglect +MV150921,50R310,RCF,4/10/2015,The facility failed to monitor Resident #2 to make sure he/she drank his/her hot chocolate containing medication. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV152155,50R310,RCF,7/10/2015,The facility failed to assess and update Resident #2's care plan for interventions associated with his/her aggressive behavior. Resident #1 and Resident #2 were involved in a resident to resident altercation. This failure is a violation of Oregon Administrative Rules.,2,,,, +MV151757,50R310,RCF,6/25/2015,The facility failed to adequately plan Resident #1's discharge. Resident #2 was able to move out of the facility without facility knowledge. This failure is a violation of Oregon Administrative Rules.,2,,,, +MV153280,50R310,RCF,5/12/2015,"Resident #5 had several instances of both verbal and physical aggression towards multiple other residents. The facility failed to adequately implement interventions to prevent Resident #5s aggression towards others. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +MV164138,50R310,RCF,12/28/2015,"The facility failed to adequately plan care and monitor Resident #1 in relation to alterations with other residents. Resident #1 had a history of altercations with other residents. Resident #1 got into another altercation with Resident #2, and Resident #2 sustained scratches and a bruise. This failure is a violation of resident rights, is considered neglect of and constitutes abuse.",2,250,,,Neglect +MV164139,50R310,RCF,12/25/2015,"The facility failed to adequately plan care in relation to Resident #2's history of aggressive behavior. On several occasions Resident #2 has shown aggression towards facility staff and other residents. Resident #2 got into an altercation with Resident #1, and Resident #1 sustained a skin tear. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +NW118369,50R311,RCF,6/7/2011,"The facility failed to ensure Resident #1 was safe before calling off the search when she/he was discovered missing. The facility failed to provide a safe environment. Resident #1 was discovered the following day and was transported to the hospital for treatment. The failures are violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NW120176,50R311,RCF,4/14/2012,"Resident #1's medication order was improperly transcribed on the medication administration record resulting in the resident not receiving her/his medication as ordered. Resident #1 experienced lethargy as a result of the medication error. The facility failed to provide a safe medication administration system. The facility also failed to provide access to facility and resident records. The failures are violation of resident rights, are considered neglect of care and constitutes abuse.",2,250,,,Neglect +NW120313,50R311,RCF,4/13/2012,"Resident #1 had a diagnosis that required administration of specific medication and monitoring. The facility failed to appropriately monitor and administer medication as ordered. Resident #1 experienced a medical condition that required transportation to the hospital for treatment. The facility also failed to provide access to facility and resident_x001A_s records. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. RP2 was also found responsible for abuse (neglect).",3,300,Substantiated,Substantiated,Neglect +NW120634,50R311,RCF,5/16/2012,"Resident #1 resided in a memory care community and was care planned for a therapeutic diet based on physician orders. The facility failed to follow orders and care plan resulting in unreasonable discomfort to Resident #1. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +NW120645,50R311,RCF,5/12/2012,Resident #1 eloped from a window in a model room that is empty by removing the stoppers and was discovered in the parking lot shortly after. Resident #1 had no prior history of elopement. The facility screwed all windows shut and the resident was put on 10 minute checks. The Department determined that the facility appropriately addressed the incident. The facility did fail to fully cooperate with an investigation and provide facility documentation as required. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NW120659,50R311,RCF,5/15/2012,"Resident #1 removed a window and screen located at the end of a hallway and eloped. Resident #1 was found several blocks away and returned before the facility was aware of the resident_x001A_s absence. Resident #1 sustained a scratch to her/his arm and forearm and had a sore foot. The facility failed to provide a safe environment resulting in minor harm with the potential for moderate harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NW120906,50R311,RCF,6/27/2012,"W2 was a new employee being trained by RP2 when Resident #1 experienced a change of condition that required medical intervention. RP2 instructed staff to call 911 and then left the building. When EMTs arrived, they had to find a staff member to have Resident #1's door unlocked. Facility staff were unable to provide necessary information that EMTs required prior to transporting to the hospital for treatment. The facility failed to ensure a qualified caregiver was present resulting in the potential for serious harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +NW120912,50R311,RCF,5/31/2012,Resident #1 required a low sugar diet due to her/his medical condition. Resident #1 required assistance with appropriate food choices and it is unclear if the facility was consistently providing this service. The facility failed to administer Resident #1 her/his insulin medication for two days resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO13009,50R311,RCF,1/24/2013,See License Condition for details (RCFCP13-002),3,0,,,Neglect +NW133802,50R311,RCF,3/30/2013,Reported Perpetrator 2 (RP2) and Resident #1 were in an altercation where RP2 forcibly pushed Resident #1's hands to his/her side. Resident #1 sustained bruises to his/her wrists and a skin tear to his/her forearm. The facility failed to protect Resident #1 from rough treatment. The failure is a violation of Oregon Administrative Rules. RP2 caused harm to Resident #1 and is responsible for abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +NW147752,50R311,RCF,2/27/2014,"Resident #1 was admitted to the memory care community on or about January 15, 2014. Facility documentation and witness testimony revealed the facility failed to adequately evaluate, monitor, assess, care plan, document and coordinate services after Resident #1 experienced a significant change of condition resulting in the development and worsening of decubitus ulcers. The facility also failed to ensure that adequate, qualified staff were available to meet residents' needs resulting in lack of ADL care and improper use of a gait belt. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +NW148036,50R311,RCF,4/8/2014,"Resident #1 was identified as a fall risk, care planned for standby assist and ensure she/he had her/his walker. Facility documentation revealed Resident #1 experienced numerous fall, some resulting in injury requiring transportation to the hospital. The facility failed to adequately care plan and monitor resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to the fact that the facility has entered into a Letter of Agreement with the Department resulting in independent management consultant oversight.",3,,,,Neglect +NW148043,50R311,RCF,7/18/2014,"The facility failed to provide the basic care and service needs as care planned for Resident #1. The facility also failed to ensure adequate, awake staff to meet the care needs of residents. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A Letter of Agreement was issued on or about August 8, 2014.",3,,,,Neglect +NW148935,50R311,RCF,8/12/2014,Resident #1 was observed shortly after exiting the building through a propped open door in the secure memory care facility. The facility failed to ensure a safe environment resulting in Resident #1's successful elopement out of the building. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW148936,50R311,RCF,8/25/2014,The facility failed to ensure a safe environment resulting in Resident #1's successful elopement out of the building. Resident #1 was returned immediately without harm. The door alarms were not functioning correctly and the investigation was unable to determine how the resident exited. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW151192,50R311,RCF,3/23/2015,"The facility failed to adequately address Resident #1's behaviors resulting in continued negative behavior. The facility also failed to ensure adequate staffing to meet Resident #1's increased behaviors. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NW149124,50R311,RCF,10/20/2014,RP2 did not respect Resident #1's right to refuse service when she/he forcibly attempted to get Resident #1 to take a shower. The facility failed to ensure Resident #1 was treated with respect and dignity. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW148357,50R311,RCF,7/30/2014,"The facility failed to adequately care plan and monitor Resident #1 resulting in multiple falls with injury that required treatment. Investigative findings revealed the facility failed to have an adequate call system to respond to residents when needed. The facility also failed to follow medication orders after returning from the hospital. The failures are violations of resident rights, are considered neglect of care and constitutes abuse. A civil penalty was warranted, however not issued due the fact that the facility entered into a Letter of Agreement on August 8, 2014.",3,,,,Neglect +NW152088,50R311,RCF,1/22/2015,"The facility failed to ensure Resident #1 received adequate services to meet her/his needs. Resident #1's care plan was not being followed and her/his room was found to be unsanitary. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NW152854,50R311,RCF,9/5/2015,"Resident #1 had a history of intrusive wandering and Resident #2 had a history of aggressive and agitated behavior. Witness testimony and facility documentation revealed a prior verbal altercation when Resident #1 wandered into Resident #2_x001A_s room. Resident #s care plan failed to address her/his behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NW148359,50R311,RCF,8/1/2014,Resident #1 eloped from the building and was later transported back to the facility without harm. It was unable to determine how Resident #1 eloped. The facility failed to ensure a safe and secure environment resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW152080,50R311,RCF,1/28/2015,"Resident #1 was a known wanderer and care planned for staff to be aware of where she/he was at. Resident #2 was a new resident and observed to get frustrated at Resident #1 for following her/him. Resident #1 was redirected. A short while later, Resident #2 was observed to push Resident #1 resulting in a fall with injury. The facility failed to adequately monitor resulting in harm. The failure is a violation of resident rights, is considered nelgect of care and constitutes abuse. A civil penalty is warranted, however not issued due to a Letter of Agreement issued on or about May 8, 2015.",3,,,,Neglect +NW152089,50R311,RCF,2/19/2015,"The facility failed to assess and intervene after Resident #1 experienced significant changes of conditions related to falls and body spasms resulting in multiple falls with injury. The failures are violation of resident rights, are considered neglect of care and constitutes abuse. A civil penalty is warranted, however not issued due to the issuance of a Letter of Agreement executed on May 8, 2015.",3,,,,Neglect +NW152173,50R311,RCF,6/10/2015,The facility failed to ensure a secure environment resulting in the successful elopement of Resident #1. Resident #1 was found just outside the doors of the memory care wing and was quickly returned without incident. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW152091,50R311,RCF,4/29/2015,"Resident #1 experienced a fall with injury that required transporation to the hospital. Investigative findings revealed the facility failed to address Resident #1's significant change of condition related to falls resulting in continued falls with injuries. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A civil penalty is warranted, however not issued due to a Letter of Agreement that required a Mangement Consultant was issued on May 8, 2015.",3,,,,Neglect +NW152172,50R311,RCF,4/23/2015,"Resident #1 was observed with an injury of unknown injury and an investigation was initiated. During the course of the investigation, facility records showed Resident #1 experienced multiple bruising and injuries of unknown origin. There was no evidence of adequate investigations related to the injuries were completed, interventions implemented or that appropriate parties were notified. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A civil penalty is warranted, however not issued due to a Letter of Agreement signed on May 8, 2015.",3,,,,Neglect +NW152175,50R311,RCF,6/13/2015,The facility failed to ensure a safe environment resulting in the successful elopement of Resident #1 from the secured memory care wing. Resident #1 was found in the Assisted Living portion of the building and returned without harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW164260,50R311,RCF,8/5/2015,The facility failed to ensure a safe medication administration system resulting in Resident #1 receiving another resident's medication. There was no known harm as a result of the error. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW164390,50R311,RCF,10/30/2015,"Resident #1 has a history of aggressive behavior when someone enters her/his room and Resident #2 was a known wanderer. Resident #1 yelled and slapped Resident #2 when Resident #2 entered Resident #1's room. The facility failed to adequately monitor Resident #2 as care planned resulting in an altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NW152111,50R311,RCF,4/15/2015,"Resident #1 fell during a one person transfer resulting in a previous wound to be reopened. Resident #1 care plan directed staff to conduct a one person transfer unless Resident #1 was weak, requiring a two person transfer. Resident #1's care plan failed to direct staff on how to determine Resident #1's weakness. The facility failed to ensure Resident #1's care plan provided clear staff direction. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO12087,50R313,RCF,7/11/2012,"The facility failed to evaluate, develop appropriate interventions, monitor and provide an RN assessment. The facility also failed to provide timely medical intervention and consistently coordinate the provision of services with outside health providers. Resident #1 had worsening skin breakdown. Resident #3 lost a severe amount of weight and experienced worsening symptoms of a urinary tract infection. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,,Neglect +BO135380,50R313,RCF,12/11/2013,"Resident #1 eloped from the assisted living side of the community and was moved to the memory care side. Resident #1 then eloped from the memory care side of the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14249,50R313,RCF,11/6/2014,"The facility failed to ensure compliance with the health care services regulations. + +The facility also failed to ensure residents were evaluated and monitored in accordance with their physical health status and significant changes of condition. Resident #1 experienced a fall that resulted in a fractured right shoulder. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BO149733,50R313,RCF,10/26/2014,"Resident #1 was exhibiting signs of illness due to coughing and increased temperature. Resident #1's physician had ordered that he/she be transported for chest x-rays and a C2 test. When Resident #1 was taken to the hospital he/she was admitted with pneumonia and a UTI that had gone septic. The facility failed to timely coordinate health services for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BO151859,50R313,RCF,5/30/2015,"The facility failed to adequately monitor Resident #1 to keep him/her from entering another residents room unsupervised. Resident #1 was found in Resident #2's room touching Resident #2 inappropriately. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BO152759,50R313,RCF,8/10/2015,"A lump and bruise was discovered on Resident #1's back during morning care. Resident #1 ambulates without assistance from staff. Resident #1 was transported to the hospital for an x-ray. Resident #1 sustained a Thoracic spine fracture. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES117169,50R314,RCF,6/4/2011,"The facility failed to care plan and implement an alternate method for Resident #1_x001A_s evening/night transfers due to his/her tiredness. Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 transferred Resident #1 who was asleep with the _x001A_Sit-Stand-Lift_x001A_ equipment. He/she began to slip; the belt was tightened by RP2, and was around Resident #1_x001A_s chest and under armpits causing injury.",2,0,Substantiated,Substantiated,Neglect +BC147087,50R316,RCF,4/30/2014,"Resident #1 visited his/her new physician and lesions were found on his/her breast. The facility had no documentation regarding Resident #1 having lesions. Resident #1's service plan stated he/she was to have daily skin checks and any lesions were to be reported. Upon interview, caregivers thought it had already been reported. The facility failed to follow Resident #1's service plan regarding skin checks. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC151567A,50R316,RCF,6/10/2015,Resident #1 had as needed pain medication that was being administered by the facility. Complainant reported that the facility was not administered Resident #1 her/his medication as prescribed. Investigative details revealed that the resident did receive more medication than prescribed resulting in the potential for harm. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.,2,,,, +BH129468,50R318,RCF,2/21/2012,"Resident #1 had a history of falls. On February 11, 2012, Resident #1 fell in his/her apartment causing a hip fracture. The facility failed to report and investigate incident. The failure is a violation of Oregon Administrative Rules.",2,300,,, +BH120219B,50R318,RCF,5/13/2012,The facility failed to report potential or suspected abuse. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH146458,50R319,RCF,2/28/2014,"On or about 2/28/14, Resident #1 was not appropriately assessed and care planned for transfer needs when he/she was admitted to the facility. Resident #1 lied in bed for 12 days and 12 nights due to the facility failing to provide adequate transfer equipment for Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse. **This Notification of Findings was completed at a later date; therefore a civil penalty was not issued due to the extended period of time between the incident date and processing by the Department.**",3,,,,Neglect +HB116234,50R320,RCF,1/11/2011,"Two Facility residents were involved in a negative physical altercation that resulted in no injury to either resident. The two residents went on to have another 3 altercations that resulted in no injury. During the time the residents began having altercations, the Facility did not change either resident's service plan to put interventions in place.",1,0,,, +HB117766,50R320,RCF,8/13/2011,Failed to ensure documentation of non-pharmacological interventions were attempted prior to administering prn medication. The failure is a violation of OARs.,2,0,,, +HB118148,50R320,RCF,9/20/2011,Resident #1 was a fall risk and care planned for staff to place a pillow beneath outside edge of mattress for safety. RP2 did not place a pillow under Resident #1's mattress as directed. Resident #1 was found on the floor next to her/his bed with a head wound that required transportation to the hospital for treatment. The facility failed to ensure the care plan was being followed. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for neglect of care and constitutes abuse.,3,0,Not Substantiated,Substantiated,Neglect +HB121960,50R320,RCF,12/23/2012,"Resident #1 eloped from the facility. Resident #1 has a history of elopement from the facility. Resident #1 reported he/she fell and sustained skin tears. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HB133307,50R320,RCF,5/25/2013,Witnesses stated Resident #2's agitation increased in the last two months. Resident #2's Care Plan stated he/she wandered into other resident's rooms and became agitated. Resident #1 was struck by Resident #2 on two separate occasions while in Resident #1's own room. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB133897A,50R320,RCF,7/24/2013,Resident #1's wrist call light was found out of his/her reach on several occasions. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB153407,50R320,RCF,11/2/2015,"Resident #1 was admitted to the facility with a history of being very protective of room. Facility documentation revealed Resident #1's verbally aggressive behaivor and threats to Resident #1 whom also resided in the same room. The facility failed to adequately address Resident #2's behavior resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,,,,Neglect +BC129951,50R321,RCF,4/30/2012,RP2 administered twice the prescribed dosage of narcotic medication to Resident #1. Facility addressed the issue and notified appropriate parties. There was no observable negative outcome as a result of the medication error. The facility failed to ensure Resident #1 received medication as prescribed resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC132585,50R322,RCF,3/4/2013,"Resident #1 became angry and struck Reported Perpetrator 2 (RP2). + +RP2 reacted by grabbing Resident #1_x001A_s shirt and seating him/her in their wheelchair. RP2 was a new caregiver and his/her training consisted of shadowing another employee for a couple of days. RP2 was not trained to deal with residents with behaviors. The facility failed to provide a safe environment and provide staff with training and interventions regarding behaviors. The failures are a violation of Oregon Administrative Rules.",2,0,,, +BC146246,50R322,RCF,3/1/2014,Resident #1 was administered another resident's medication. The error was discovered immediately and Resident #1's medical provider was notified. The medical provider requested that Resident #1 be transported to the hospital for observation and was returned to the facility within a few hours with no treatment. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS116098,50R323,RCF,1/7/2011,An unidentified staff person of the facility provided the secure door code to the unit where Resident #1 resided exposing him/her to potential for harm.,2,0,,, +MS118699A,50R323,RCF,11/14/2011,"The facility failed to follow Resident #1's treatment plan for his/her wound care, resulting in worsening of the wounds. He/she was transferred to a higher skilled facility due to the seriousness of his/her wounds.",2,0,,,Neglect +MS118699B,50R323,RCF,11/14/2011,Resident #1 was prescribed a medication to be administered twice daily for infection. The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving his/her morning medication for approximately four days.,2,0,,, +MS121718,50R323,RCF,11/26/2012,Resident #1 was administered the wrong medications; those belonging to his/her spouse instead of his/her own. A couple of the medications were the same at Resident #1's but not all. Resident #1 had no observable ill effects. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +MS132466,50R323,RCF,2/21/2013,"Resident #1 was dependent on staff for transfers and all care. The facility failed to provide appropriate care resulting in two fractures to his/her left leg. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS132626B,50R323,RCF,12/28/2012,The facility failed to assess Resident #1's injury from a fall required further action. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS132607,50R323,RCF,10/26/2012,The facility failed to provide a safe environment resulting in Resident #1's loss of money and clothing. An unknown individual is responsible for the thefts. The facility's failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MS145602,50R323,RCF,1/6/2014,"Resident #1 and Resident #2 had known prior behaviors; however were housed in the same room. The facility failed to take reasonable precautions and implement interventions regarding their behaviors resulting in an altercation between Resident #1 and Resident #2. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS146369,50R323,RCF,3/12/2014,"Resident #3 was observed exposing her/his genitalia to two residents in the common area. Resident #3 had previous behavior within the confines of her/his room. Facility staff were advised to monitor. The facility failed to appropriately care plan to address behaviors. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +MS134805,50R323,RCF,10/21/2013,"The facility failed to implement interventions and update the care plan when Resident #1's condition changed regarding falls transferring in/out of bed, on/off toilet, and not having his/her wheelchair locked. Resident #1 suffered bruising and skin tears. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS146418,50R323,RCF,3/19/2014,"The Facility failed to assess and intervene when Resident #1 experienced a change of condition. Resident #1 suffered unreasonable continued pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS148934,50R323,RCF,10/15/2014,"Resident #1 was cognitively impaired, lived in a secured environment, and had history of exit seeking. On 10/15/14, Resident #1 had eloped from the facility and was gone approximately 2.5 hours. Resident #1 was exposed to potential for harm. The facility failed to monitor Resident #1 and provide a safe environment, which are violations of Oregon Administrative Rules.",2,,,, +MS145878,50R323,RCF,1/16/2014,"Reported Perpetrator 2 (RP2) admitted to taking money from Resident #1 approximately seven or eight times. RP2's actions are considered financial exploitation and constitute abuse. The facility is responsible for the overall conduct of staff, which is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +CO14251,50R323,RCF,11/19/2014,"The facility failed to ensure a Registered Nurse assessed, documented findings, and developed appropriate interventions for Resident #4 who experienced a significant change of condition. Resident #4 experienced a worsening of skin breakdown. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS152247,50R323,RCF,7/28/2015,"The facility failed to provide adequate nursing oversight, failed to appropriately monitor residents_x001A_ evaluated needs and service plan, and failed to ensure showers were provided. Resident #1, Resident #2 and Resident #3_x001A_s care needs were unmet. Resident #1 and Resident #2 had skin issues and Resident #3 was not showered regularly and had skin issues. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS151688,50R323,RCF,6/21/2015,"Resident #1 had a history of sexually inappropriate incidents with Resident #2. Resident #2 is non-verbal and incapable of consenting. On 6/21/15, Resident #1 put his/her hands into Resident #2's brief. Resident #2 became agitated after the incident. The facility failed to implement interventions and care plan appropriately regarding Resident #1's behaviors. The facilities failures are a violation of resident rights and are considered neglect of care resulting in sexual abuse.",2,,,,Sexual abuse +MS153998,50R323,RCF,12/21/2015,"The facility failed to ensure Resident #1's service plan addressed past altercations with Resident #2 to ensure safety. Resident #1 hit Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS164151A,50R323,RCF,1/3/2016,"The investigation including witness testimony demonstrated that Reported Perpetrator 2 (RP2) yelled, used profanity, and was derogatory within hearing distance of residents. RP2's actions are considered verbal abuse. The facility failed to ensure a safe environment free from verbal abuse, which violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +MS164177,50R323,RCF,1/2/2016,"Resident #1 had a history of and was care planned for aggressive behaviors towards other residents and staff were to supervise and redirect him/her. Resident #1 slapped Resident #2 leaving Resident #2's cheek red. The facility failed to properly care plan and implement interventions to ensure resident safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS117050,50R326,RCF,5/22/2011,A resident of the Facility was administered medication belonging to another resident in addition to his/her medication of the same variety. The result of receiving the other resident's medication left the resident sedated to the extent that he/she was drooling excessively and was not acting normal.,2,0,,,Neglect +MS132032A,50R326,RCF,12/29/2012,It was reported that Reported Perpetrator 2 (RP2) grabbed Resident #1_x001A_s wrist and pushed their fingers into his/her stomach to make him/her sit down. It was also reported that RP2 pushed Resident #1 down onto his/her bed. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +MS132032B,50R326,RCF,12/29/2012,Reported Perpetrator 2 (RP2) was witnessed swearing at and speaking rudely to Resident #1. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MS132088,50R326,RCF,1/9/2013,Resident #1 and Resident #2 were involved in an altercation. There were no injuries sustained. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MF133168,50R326,RCF,5/8/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #1 hit Resident #2 in the arm. No injuries were sustained. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MF152271,50R326,RCF,7/29/2015,"Resident #2 and Resident #1 were involved in an altercation that required Resident #1 to be transported to the hospital for treatment. Both residents had a history of physical and verbal aggression. Resident #1's care plan stated staff were to know his/her proximity at all times. Resident #2's care plan stated staff were to redirect from other resident rooms. The facility failed to follow the care plan for Resident #1 and Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DL105281,50R327,RCF,9/19/2010,"Resident #1 eloped from a secure unit at the facility. He/she fell outside sustaining an injury. He/she was transported by ambulance to the hospital. The facility failed to provide a safe environment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The Notification of Findings was completed at a later date (A civil penalty was not issued) due to the extended period of time between the incident date and processing by the Department.",3,0,,,Neglect +DL148346,50R327,RCF,8/30/2014,Reported Perpetrator 2 (RP2) took video of Resident #1 sitting on the toilet without his/her permission. The unauthorized video was being shown to coworkers at the facility. It was also reported that Reported Perpetrator 3 (RP3) had videos. RP3 denied this during the investigation. RP2 admitted to taking the video. RP2's actions were a violation of resident rights and constitute emotional abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +DL150016,50R327,RCF,1/21/2015,"Resident #1 had a history of sexual behaviors. Resident #1 was found in Resident #2's room on the bed, kneeling over Resident #2 trying to kiss him/her. Both residents were fully clothed. The facility failed to adequately service plan Resident #1 for inappropriate sexual behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP150002,50R328,RCF,1/22/2015,"Resident #1 and Resident #2 had a history of physical confrontation. Both residents had cognitive deficits and Resident #1 with. On 1/20/15, Resident #1 and Resident #2 had a physical confrontation. The facility failed to care plan and implement appropriate interventions to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH146602,50R330,RCF,1/20/2014,"Resident #1 had an order for a PRN narcotic medication that was kept at the facility in a locked cabinet which was only accessible with a key. On 1/20/14 at the 6pm medication count, his/her medication was in the locked cabinet; however it was missing at the 10pm count. Interviewed staff denied taking the medications and all drug tests were negative. An unknown individual is responsible for the theft of medications, which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication administration system and the failures are a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH147409,50R330,RCF,5/5/2014,"For approximately 15 consecutive days, Resident #1 was not administered his/her AM (morning) dose of medication. His/her behaviors increased due to the medication error. The facility failed to ensure his/her medications were administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH147319,50R330,RCF,1/29/2014,The facility failed to take measures to keep Resident #1 safe from leaving the facility grounds/gate. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH153871,50R330,RCF,10/24/2015,"On 10/24/15, Resident #1 eloped from the facility and was returned without injury. His/her service plan stated staff were to escort him/her to activities. He/she had had one prior elopement however there was no documented date or incident report. The facility failed to ensure Resident #1's service plan was followed to ensure Resident #1 was safe. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +CO14078,50R331,RCF,4/2/2014,"The facility failed to ensure behavioral symptoms which negatively impacted residents and others in the memory care community were evaluated, failed to provide interventions to prevent further incidents, or had reflective service plans. Resident #2 was involved in four resident altercations and Resident #4 exhibited aggressive behavior. The facility also failed to evaluate, monitor and follow Resident #4's physician's order. Resident #4 experienced agitation, aggression and violent behavior after the facility improperly discontinued her/his nicotine patch order. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +MS129792B,50R333,RCF,4/15/2012,"RV's family was visiting RV and found him/her in a wheeled ambulation assistive device with his/her privates exposed. After investigation it was determined that the facility would cover RV up with a blanket, but at times the RV would push the blanket aside.",0,0,,, +MF133137B,50R333,RCF,5/1/2013,Reported Perpetrator 2 (RP2) befriended Resident #1 and began having a sexual relationship. RP2 encouraged the relationship more then Resident #1 did. RP2 is found responsible for sexual abuse to Resident #1. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Sexual abuse +MF133137A,50R333,RCF,5/1/2013,"Reported Perpetrator 2 (RP2) befriended Resident #1 and borrowed money from him/her. Resident #1's spending money depleted rapidly. RP2 is responsible for wrongfully taking Resident #1's money, which constitutes theft and financial exploitation. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS132979,50R333,RCF,4/15/2013,Reported Perpetrator 2 (RP2) administered another residents' medications to Resident #1. He/she suffered a drop in blood pressure and was transported to the hospital where his/her mental status was altered. RP2 failure is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system.,3,,Not Substantiated,Substantiated,Neglect +MS148245,50R333,RCF,7/6/2014,Resident #1 has a condition related to cognition and was a known wanderer with elopement history. Witness testimony and facility documentation revealed that the resident experienced multiple elopements that required assistance to return to the facility. The facility failed to timely address Resident #1's elopement to ensure a safe environment resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +MS148843,50R333,RCF,10/8/2014,Resident #1 had a condition related to memory loss and a history of elopement. Witness testimony and facility documentation revealed Resident #1 eloped from the facility. The facility failed to appropriately monitor and ensure a safe environment resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS159788A,50R333,RCF,1/5/2015,"Resident #1 had a history of wounds on feet and was care planned to monitor weekly. Witness testimony and facility documentation revealed facility staff did not check Resident #1's feet as directed. Further testimony revealed the resident had a strong, uncommon odor for the past several weeks that did not get investigated. On or about January 5, 2015, Resident #1 was transported to the hospital for treatment of gangrene on her/his foot. The facility failed to adequately monitor as directed resulting in resident harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS159788B,50R333,RCF,1/5/2015,Resident #1 had an order for administration of daily medication related to heart health. Facility documentation revealed that the medication was not administered for two months. Resident #1 also did not receive a daily dose of medication related to cholesterol for several days. Both medication were not administered due to a lack of medication in the building. The facility failed to provide a safe medication administration system resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +MS150352,50R333,RCF,2/21/2015,"Resident #1 had a history of increased aggressive behavior towards others. Resident #1 experienced a physical altercation with Resident #2 resulting in harm. Witness testimony and facility documentation revealed the facility failed to adequately care plan, monitor and provide qualified staff to address Resident #1's behavior resulting negative behavior affecting others. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS150959,50R333,RCF,4/14/2015,"The facility failed to care plan Resident #1's wandering behavior resulting in harm from a physical altercation with Resident #2. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,250,,,Neglect +MF151612,50R333,RCF,6/13/2015,"Resident #1 had a history of unsafely using her/his power chair resulting in falls. The care plan was updated to switch Resident #1 to a manual wheelchair. Resident #1 continued to experience falls. On or about June 13, 2015, Resident #1 experienced a fall with injury from her/his power chair that required transportation to the hospital for treatment. The facility failed to adequately monitor Resident #1 as care planned resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,250,,,Neglect +MS151886,50R333,RCF,7/10/2015,"The facility was managing the administration of Resident #1's medication. Investigative findings revealed multiple discrepancies between the MAR (Medication Administration Record), physician's orders, VA medication list and prescription bottles. The facility failed to ensure a safe medication administration resulting in the potential for harm and is a violation of Oregon Administrative Rules.",2,,,, +RD105930,50R334,RCF,11/30/2010,"During a routine audit, it was discovered that narcotic medication had been replaced with a nearly identical looking over-the-counter pain medication for Resident #1 and Resident #2. Resident #1 rarely used the narcotic pain medication and Resident #2 used narcotic pain medication two to three times a week; however neither resident displayed unusual behaviors or increased pain prior to the discovery.",2,0,Not Substantiated,Substantiated,Financial abuse +RD105936,50R334,RCF,11/15/2010,"The facility failed to provide a safe medication administration system resulting in the loss of residents' medications. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +RD117218,50R334,RCF,4/19/2011,"Resident #1_x001A_s PRN narcotic medications were refilled on 3/17/11, 4/7/11, and 4/16/11 with 31 pills in each bottle. Reported Perpetrator 2 signed that the medications were delivered; however none of the refilled orders were documented on Resident #1_x001A_s MAR or Narcotic Log book. Resident #1 rarely needed this PRN narcotic medication and would verbally request it if needed. There are 93 pills of his/her PRN narcotic pain medications unaccounted for. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and financial exploitation and constitute abuse.",2,250,Substantiated,Substantiated,Financial abuse +RD134026,50R334,RCF,7/28/2013,"Resident #1 and #2 had an altercation in the dining room, resulting in a skin tear to Resident #2's arm. The altercation was the third involving the two residents in a week's time, in which Resident #1 was the initiator. Despite Resident #1 being agitated and aggressive on the day of the incident; facility staff observed Resident #2 walking into the dining area where Resident #1 was sitting and did not attempt to re-direct Resident #2 away from the area. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD135111,50R334,RCF,9/27/2013,"On 9/26/13, it was discovered that at least 57 different pills/medications were found in Reported Perpetrator 2's (RP2) belongings; and none of them were narcotic medications. Documentation indicates all medications were administered and there were no documented refusals of medications by residents, and no documented ill effects of the residents. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules. RP2's action constitutes abuse by financial exploitation.",2,,Not Substantiated,Substantiated,Financial abuse +CO14252,50R334,RCF,12/3/2014,"The facility failed to ensure a Registered Nurse (RN) assessed and documented findings in order to develop appropriate interventions for Resident #2 who experienced significant changes of condition. Resident #2 experienced episodes of uncontrolled pain after a fall, and a hip fracture was untimely diagnosed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH117472A,50R336,RCF,7/18/2011,RP2 was observed hitting Resident #1 several times on the back of the head. Resident #1 was heard saying ouch. The facility failed to protect Resident #1 from rough treatment resulting in physical abuse by RP2. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +BH117472D,50R336,RCF,7/18/2011,Resident #2 reported to staff she/he was kicked by someone. Staff failed to timely report incident. The facility failed to ensure staff timely reported suspected abuse. The failure is a violation of OARs.,2,0,,, +BH134323,50R336,RCF,7/6/2013,Reported Perpetrator 2 (RP2) raised his/her voice to Resident #1 and used foul language while telling him/her to sit down on the toilet. RP2 was also heard using foul language in front of another resident. The facility failed to protect Resident #1 from verbal abuse. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for verbal abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +BH146154,50R336,RCF,2/10/2014,RP2 was observed to take Resident #1's walker after she/he sat down. The facility failed to ensure Resident #1 was treated with dignity and respect and is a violation of Oregon Administrative Rules.,2,,,, +BH148478,50R336,RCF,9/2/2014,Complainant reported RP2 used physical force and verbally abusive behavior while attempting to administer medication to Resident #1. Witness testimony and facility documentation confirmed RP2 failed to follow the care plan and was physically and verbally abusive towards Resident #1. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for physical and verbal abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +BC135281,50R338,RCF,12/2/2013,"On 12/2/13, Resident #2 was observed grabbing Resident #1's breast. There were no visible marks and no adverse effects identified at that time. During the investigation, it was discovered that similar incidents occurred on 11/28/13 and 11/30/13 and were reported to Reported Perpetrator 2 (RP2); however there was no documentation completed by RP2. The facility failed to ensure RP2 reported to the administrator or the local APD office. RP2's failures are considered neglect of care resulting in resident to resident inappropriate sexual touching.",2,,Not Substantiated,Substantiated,Neglect +JG129713,50R339,RCF,12/17/2011,"Resident #1 was found on the floor at 12:30 am with a deep cut to the bottom of his/her right foot between the toes. The cut was not noticed and Resident #1 was put back into bed. The wound was not discovered until 6:30 am putting Resident #1 at serious risk due to his/her diagnosis and blood loss. The facility failed to follow Resident #1_x001A_s care plan and evaluate Resident #1 in a timely manner. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +JG129709A,50R339,RCF,12/19/2011,"Resident #1 displays frequent behaviors requiring interventions. Staff is to use redirection when Resident #1 is displaying behaviors. A merry walker has been used as a way to contain Resident #1 when redirection has failed. The facility failed to properly use a restraint. The failure is a violation of resident rights, is considered wrongful use of a restraint and constitutes abuse.",2,0,,,Restraints +JG145634,50R339,RCF,12/25/2013,"Resident #1 was given medication belonging to another resident and was transported to the hospital. Upon return to the facility, Resident #1 had not returned to his/her baseline. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +JG147234,50R339,RCF,5/23/2014,Resident #1 sustained a skin tear on his/her arm during transfer due to not having arm protectors. The arm protectors were missing for approximately two days prior the incident. The MAR indicates that he/she has an order for arm protectors but the care plan does not have information on how to follow the order. The facility failed to update Resident #1's care plan relating to arm protectors and failed to have his/her arm protectors available. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB129411,50R340,RCF,3/4/2012,"Resident #1 eloped from the facility on March 4, 2012. This was Resident #1_x001A_s second elopement. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HB133881,50R340,RCF,7/23/2013,"Resident #1 eloped from the facility on three separate occasions, even though the facility had a bed alarm system, a threshold alert and exterior thresholds that made a doorbell sound when crossed. Resident #1 injured his/her knee and arm during the third elopement, which facility staff treated with ice. Resident #1's Care Plan was not updated until after the third elopement. The facility failed to properly care plan, which is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB147064,50R340,RCF,5/13/2014,"The facility was aware that Resident #1 was an elopement risk when he/she moved into the facility. He/she began exit seeking and eloping and was difficult to redirect and sometimes redirection was unsuccessful. The facility failed to implement interventions as he/she continued exit seeking and eloping, which exposed him/her to potential harm. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +HB147540,50R340,RCF,6/26/2014,Resident #1 was an elopement risk and had eloped from the facility in the past. He/she eloped from the facility without staff noticing or hearing the alarm. He/she had no injury. The facility failed to monitor and provide a safe environment and the failures are a violation of Oregon Administrative Rules.,2,,,, +HB147741,50R340,RCF,7/15/2014,"Resident #1's medications were managed by the facility and narcotic medications were kept secured with limited access. It was discovered that seven (7) of Resident #1's narcotic medications were missing; however the search was unsuccessful and the drug tested caregivers came up negative. An unknown individual is responsible for the theft of Resident #1's narcotic medications, which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication system that prevented theft of medications. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB149225,50R340,RCF,11/12/2014,The facility failed to take reasonable precautions and failed to implement interventions regarding Resident #1's behaviors of exit seeking and elopement. Staff escorted and left Resident #1 unsupervised at a local establishment and he/she later left unsupervised. He/she was found and returned unharmed to the facility. The facilities failures put Resident #1 as risk for harm and are a violation of resident rights and Oregon Administrative Rules.,1,,,, +HB152328,50R340,RCF,8/3/2015,"Resident #1 had impaired cognition, was an elopement risk and fall risk. Resident #1 eloped from the facility, didn't have a locater bracelet, was attended to by paramedics and transported to the hospital for observation and was later returned to the facility. The facility failed to adequately care plan and implement interventions regarding his/her cognition and elopement risk. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB151368A,50R340,RCF,5/26/2015,"The facility failed to implement and care plan interventions regarding exit seeking and elopement behaviors of Resident #1, Resident #2, and Resident #3 to ensure a safe environment. The failures exposed the residents to potential harm and violate Oregon Administrative Rules.",2,,,, +HB151368B,50R340,RCF,5/26/2015,"The facility failed to appropriately implement and care plan interventions regarding Resident #6's physical aggression of hitting staff, residents, and his/her spouse resulting in an unsafe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB151368C,50R340,RCF,5/26/2015,"Resident #7's narcotic medication was off, staff signed off on the incorrect amount and did not report discrepancy. The facility failed to ensure a safe medication administration system, failed to have a system in place for narcotic medication counts, and failed to ensure staff were trained in proper medication recording and reporting of discrepancy. The failures are a violation of resident rights and violate Oregon Administrative Rules.",2,,,,Neglect +GP116374,50R343,RCF,2/16/2011,Reported Perpetrator 2 (RP2) hit Resident #1 after he/she swung at RP2. Resident #1 fell and sustained a skin tear to his/her right forearm.,2,0,Not Substantiated,Substantiated,Physical Abuse +GP121415,50R343,RCF,10/22/2012,"Based upon the investigation, it was determined that the facility failed to provide service to residents. The failure is a violation of Oregon Administrative Rules.",2,0,,, +GP132328,50R343,RCF,2/5/2013,"Reported Perpetrator 2 (RP2) admitted stealing pain medications from Resident #1, Resident #2 and Resident #3 over a period of time. RP2 is found responsible for the theft of medications, constituting abuse. The facility failed to provide a safe medication administration system that prevented theft of medications and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +GP151138B,50R343,RCF,5/4/2015,"Resident #1, #2 #3, #5 and #6 were not receiving skin ointment as ordered by the medical provider. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO15253,50R343,RCF,11/18/2015,"A re-licensure survey completed on November 18, 2015, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to ensure residents were evaluated and monitored according to their needs. The facility also failed to ensure referrals for Registered Nurse assessments were made and failed to ensure monitoring and evaluation of Residents. Resident #1 had pressure ulcers with no evaluation. Resident #2 experienced a significant weight loss with no evaluation. Resident #3 experienced significant weight loss and lost additional weight with no evaluation. Resident #4_x001A_s record lacked documentation or evaluation regarding an intimate relationship with another resident. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,1200,,,Neglect +GP164217,50R343,RCF,1/8/2016,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 had a history of aggressive behavior with staff and other residents. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD116817,50R344,RCF,3/15/2011,"Reported Perpetrator 2 (RP2) sat Resident #1 in a recliner, pulled the foot rest up, and wrapped a blanket around him/her in such a way that he/she could not get out of the chair on his/her own. Witness 3 removed the blanket and assessed with no injury noted; however Resident #1 was agitated and the next morning would no longer sit in that particular chair.",2,0,Not Substantiated,Substantiated,Restraints +RD117126,50R344,RCF,4/13/2011,"Resident #2 threw a cup of lukewarm coffee on Resident #1 when he/she bumped his/her wheelchair into Resident #2's wheelchair in the dining area. Staff assisted Resident #1 to get cleaned up and as he/she returned to the dining area, Resident #2 poked Resident #1 in the shoulder with a fork. Staff failed to keep Resident #1 safe from Resident #2 after the first incident resulting in a second incident.",2,0,,, +RD118225,50R344,RCF,9/14/2011,"Resident #1 has a history of wandering into others rooms and falling asleep on their beds. The facility failed to care plan for interventions when Resident #1 goes to sleep in other resident_x001A_s beds. The facility failed to provide a safe environment resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Physical Abuse +RD116283,50R344,RCF,1/7/2011,"Resident #1 has a history of aggressive behavior and her/his care plan indicated signs of agitation include unable to be redirected. On January 9, 2011 facility failed to intervene after Resident #1 was unable to be redirected resulting in Resident #2 being hit. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RD132770,50R344,RCF,2/14/2013,Reported Perpetrator 2 failed to administer medications as ordered. No adverse reactions were reported. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BO149721,50R344,RCF,10/18/2014,"The facility failed to adequately monitor Resident #2_x001A_s wandering behavior. Resident #2 entered Resident #1_x001A_s room, and startled Resident #1 causing him/her to fall. Resident #1 was sent to the hospital and was determined to have sustained a hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD150413,50R344,RCF,1/19/2015,Reported Perpetrators #2 and #3 (RP2 and RP3) forcibly removed Resident #1 from another residents room causing bruising to Resident #1's hand. RP2 and RP3 are responsible for physical abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +RD151349A,50R344,RCF,5/2/2015,"The facility failed to adequately monitor Resident #1 and Resident #2 as indicated in their care plans. Both Residents had a history of aggression towards each other and were to be monitored when they were in close proximity to each other. Resident #1 and Resident #2 were no monitored closely, got into an altercation, and Resident #1 punched Resident #2. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,250,,,Neglect +RD151349B,50R344,RCF,5/2/2015,"The facility failed to adequately monitor Resident #1 when he/she was in close proximity to Resident #2 as indicated in his/her care plan. Resident #1 followed Resident #2 into Resident #2's bathroom and slapped him/her several times. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,250,,,Neglect +RD153864A,50R344,RCF,12/5/2015,"The facility failed to adequately monitor Resident #1, and Resident #1 was able to elope from the facility. Law enforcement was able to locate Resident #1 and return him/her to the facility without injury after about an hour. This failure is a violation of Oregon Administrative Rules",2,,,, +RD164228,50R344,RCF,1/6/2016,"The facility failed to adequately monitor Resident #1 as indicated in his/her care plan. Facility staff were to have awareness of where Resident #1 was at all times given his/her behavior of following Resident #2 around. Resident #2 and Resident #1 got into an altercation, and Resident #1 was pushed down with no injury. This failure is a violation of Oregon Administrative Rules.",2,,,, +BO164540,50R344,RCF,1/1/2016,The facility failed to adequately provide a safe environment in relation to Resident #1 eloping from the facility. Resident #1 has a history of exit seeking behavior and was able to leave the facility until care staff noticed him/her in the parking lot. This failure is a violation of Oregon Administrative Rules.,2,,,, +OR0001046400,50R344,RCF,12/31/2015,,0,,,Substantiated, +ES103800,50R345,RCF,3/17/2010,Facility failed to follow Resident #2's Service Plan resulting in the resident being pushed by another resident. The failure is a violation of OARs.,2,0,,, +ES116427,50R345,RCF,2/23/2011,"The facility failed to adequately care plan after Resident #1 and Resident #2 had previous physical altercation in which Resident #1 struck Resident #2 resulting in another physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES116520,50R345,RCF,3/13/2011,Resident #2 was observed pushing Resident #1. Resident #1 had a history of getting into others personal space and service plan directed to monitor resident and intervene. Staff observed Resident #2 push Resident #1 but were unable to intervene in time. The facility failed to follow service plan. No harm occurred as a result of the incident.,2,0,,, +ES117855,50R345,RCF,8/26/2011,"The facility failed to address Resident #1's aggressive behavior resulting in the potential for harm to residents. On August 27, 2011, Resident #1 and Resident #2 experienced a physical altercation in which Resident #1 hit Resident #2 with a cup. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES117391,50R345,RCF,7/3/2011,"Facility failed to adequately monitor and address Resident #1's aggressive behavior resulting in physical altercation and minor harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES118650,50R345,RCF,12/8/2011,Resident #1 reported $180 - $200 missing from her/his room and suspected RP2 of taking it. There is no evidence to conclude RP2 was responsible for the theft. The facility failed to provide a safe evironment resulting in the loss of Resident #1's money. Abuse was apportioned to an unknown individual.,3,0,Not Substantiated,Substantiated,Financial abuse +ES117688,50R345,RCF,8/4/2011,"Resident #1 and Resident #2 had a history of physical altercations and care planned to keep separated. On or about August 4, 2011, facility staff observed the two residents together, but failed to separate resulting in a physical altercation. The facility failed to ensure residents' service plans were followed resulting in a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES118223,50R345,RCF,10/11/2011,"The facility failed to adequately address Resident #1's aggressive behavior resulting in numerous physical altercations with other residents. The failure is a violation of resident rights, is considered negelct of care and constitutes abuse.",2,250,,,Neglect +ES118325,50R345,RCF,10/28/2011,"The facility failed to implement interventions for Resident #1's known behaviors. Resident #2 was hit by Resident #1, leaving him/her frightened of Resident #1.",2,0,,,Neglect +ES118465,50R345,RCF,11/5/2011,The facility failed to adequately address and implement interventions for Resident #1's aggressive behaviors resulting in increased altercations.,2,250,,,Neglect +ES118788B,50R345,RCF,12/26/2011,"Resident #1 had a history of aggressive behavior and multiple altercations with other residents. On December 25, 2011, Resident #1 had increased aggressive behavior that continued the following day resulting in altercations with other residents. On December 27, 2011, Resident #1 continued to have aggressive behavior that resulted in pulling Resident #4's hair. The facility failed to provide appropriate interventions resulting in harm to another resident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +ES129523,50R345,RCF,3/16/2012,Resident #1 requires one person assist with toileting. Resident #1 became combative and smeared feces all over RP2 while being assisted with peri-care. RP2 attempted to stop Resident #1 from leaving the bathroom with pants around ankles causing bruising and skin tears. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES118629,50R345,RCF,11/5/2011,Facility staff requested assistance after Resident #1 was being combative. Resident #1 pulled RP2's hair three times and RP2 responded by pulling Resident #1's hair. Resident #1 screamed. The facility failed to protect Resident #1 from rough treatment and is a violation of Oregon Administrative Rules. RP2 was held responsible for rough treatment and is considered physical abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +ES129976,50R345,RCF,5/3/2012,"On the morning of May 4, 2012, staff noticed Resident #1's liquid narcotic medication looked different and determined it was diluted. Resident #1 did not receive pain medication until the afternoon. The facility failed to administer medication as ordered resulting in Resident #1 experiencing unrelieved pain. It was undetermined how the medication became diluted.",2,0,,,Neglect +ES120182,50R345,RCF,5/31/2012,"Resident #2 was observed to shake Resident #1 resulting in a small bruise. There have been two previous incidents involving these two residents. The facility failed to appropriately address Resident #2's behavior resulting in minor harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES121066,50R345,RCF,9/14/2012,Staff discovered non-narcotic pain medication for Resident #1 was missing from the medication room. Resident #1 did not have any negative outcome as a result. The facility failed to provide a safe environment resulting in the loss of Resident #1's pain medication. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES120420,50R345,RCF,6/30/2012,Resident #1 had a history of physical aggression toward other residents. There had been three other incidents in a three monthly period. Resident #1 wandered into Resident #2_x001A_s room and a physical altercation occurred. There were no injuries. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES148106,50R345,RCF,8/11/2014,"Resident #1 exhibited behaviors towards three residents, resulting in Resident #2 being slapped. The facility failed to adequately monitor and provide a safe environment resulting in minor harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES147464,50R345,RCF,6/17/2014,Resident #1 had a history of agitated and aggressive behaviors towards anyone. The facility failed to adequately address Resident #1's behaviors resulting in continued altercations. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148761,50R345,RCF,9/30/2014,Resident #1 experienced a significant change of condition and the care plan was updated to require two person assistance with all transfers. RP2 attempted to transfer Resident #1 by her/himself and the resident was guided to the floor when her/his legs gave out. The facility failed to ensure the care plan was followed resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148760,50R345,RCF,9/30/2014,"Resident #1""s care plan directed staff to ensure she/he and Resident #2 remain separated in the dining area. On or about September 30, 2014, staff observed Resident #1 and Resident #2 next to eachother. Resident #1 kicked Resident #2. The facility failed to ensure Resident #1's care plan was followed resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES145863,50R345,RCF,12/29/2013,"The facility failed to adequately monitor and intervene after Resident #1 experienced a change of condition relating to skin breakdown and resulted in the worsening of Resident #1's wounds. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A civil penalty is warranted, however not issued due to the timeframe between the investigation and when it was processed.",3,,,,Neglect +ES150183,50R345,RCF,2/7/2015,"Resident #2's care plan required supervision when not in her/his room. The facility failed to ensure Resident #2's care plan was followed resulting in bruising from an altercation with Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES149570,50R345,RCF,12/12/2014,The facility failed to adequately care plan and monitor surrounding Resident #1's behavior resulting in an altercation with Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES150584,50R345,RCF,3/15/2015,"Resident #1 had a history of aggressive behavior. The facility failed to adequately monitor as care planned resulting in Resident #2 being slapped. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +ES148917,50R345,RCF,10/15/2014,Resident #1 was care planned as a two person transfer. RP2 unsuccessfully attempted to transfer Resident #1 on her/his own resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +ES148918,50R345,RCF,10/14/2014,The Facility failed to ensure residents' care plan was followed resulting in an altercation. There was no harm as a result of the incident. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES151786,50R345,RCF,6/29/2015,"Resident #2 had a known history of aggressive behavior and did not like when others entered her/his room. Resident #1 had a history of wandering into other residents' room. The facility failed to monitor as care planned resulting in Resident #1 being hit by Resident #2 when Resident #1 entered the other resident's room. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES152337,50R345,RCF,7/31/2015,"Resident #1 has a known history of aggressive behavior when she/he believes their item has been taken. The facility failed to adequately monitor residents resulting in a physical altercation. Resident #1 pushed and kicked Resident #2 when she/he thought that the resident took a remote. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES152019,50R345,RCF,7/9/2015,"Resident #1 had a history of aggressive behavior and care planned for one on one care when the resident is outside of her/his room. The facility failed to follow the care plan resulting in an altercation with Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES153562,50R345,RCF,11/13/2015,"The facility failed to provide a safe medication administration system resulting in unreasonable discomfort. Resident #1 did not receive scheduled narcotic medication for 4 days. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC149739,50R346,RCF,12/26/2014,"The facility failed to ensure a safe environment resulting in Resident #1 being transporated to the hospital from a medication error. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES105272,50R347,RCF,8/4/2010,A resident of the Facility was discovered to have had $260.00 removed from his/her room without his/her knowledge or consent. The money was not recovered. The Facility offered to refund the resident the amount he/she was missing.,2,0,,,Financial abuse +ES116481,50R347,RCF,2/17/2011,"A resident of the Facility was in another resident_x001A_s room causing a disruption. One Facility staff member asked another staff member, Reported Perpetrator #2 (RP2) for assistance with removing the resident. RP2 was seen to grab the resident with excessive force by the resident_x001A_s wrist(s). The resident later developed bruising as a result. The Facility failed to report the incident to the Department timely.",2,0,Not Substantiated,Substantiated,Physical Abuse +ES117177,50R347,RCF,5/27/2011,"A resident of the Facility pulled a ladder on his/her self that a staff member was using to access an elevated crawl space for the purpose of changing out air filters. The staff member had previously been asked to have a spotter for the ladder, to avoid incidents with residents who may come into contact with the ladder.",2,0,,,Neglect +ES133777,50R347,RCF,7/11/2013,"Resident #1 and Resident #2 were affected by Witness #9_x001A_s inappropriate sexual behaviors and were exposed to potential for serious harm. The facility failed to care plan appropriately and implement interventions regarding Resident #1 and Witness #9_x001A_s behaviors and failed to report to Adult Protective Services. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse.",2,2500,,,Sexual abuse +ES148611,50R347,RCF,9/18/2014,"Resident #1 is completely dependent upon the facility for all care. He/she is unable to reposition him/herself during the night and requires repositioning every two hours to reduce risk of injury/skin breakdown. Resident #1 was not repositioned during the night and slept on his/her right arm, which caused swelling and blisters. The facility failed to appropriately care plan regarding repositioning every two hours. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse",12,,,,Neglect +ES147023,50R347,RCF,5/8/2014,"Resident #1 had two checks missing from his/her room. Witness #4 (Reported Perpetrator 2's significant other) attempted to cash one of the checks at Resident #1's financial institution. The check was declined due to the signature not matching Resident #1's. Reported Perpetrator 2 (RP2) was found responsible for theft which constitutes financial exploitation. + +The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +ES152405,50R347,RCF,8/1/2015,It was reported that Resident #1's diamond earrings were missing from his/her room. An unknown individual was found responsible for the loss of Resident #1's earrings which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES153781,50R347,RCF,11/27/2015,"Resident #2 slapped Resident #1. Resident #2 had a history of altercations. No injuries were sustained. The facility failed to follow Resident #2's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD116327B,50R349,RCF,1/10/2011,Resident #2 had a physician's order for liquid cough syrup to be administered nightly. He/she was out of the facility for two days; however on the day of return it was discovered that his/her bottle had been tampered with. A new bottle was ordered and received on the same day and a new monitoring system implemented.,2,0,,, +RD117326,50R349,RCF,4/5/2011,"Resident #1's and Resident #2's bottles of narcotic PRN pain medication were discovered to have been replaced with a very similar looking over the counter pain medication. All medications were counted at each shift and the writing on the narcotic pain pills looked unusual, discovering the misappropriation. Video footage revealed Reported Perpetrator 2 (RP2) replaced the narcotic medication with an over the counter pain medication. RP2 admitted to misappropriating narcotic pain medications.",2,0,Not Substantiated,Substantiated,Financial abuse +RD132012,50R349,RCF,12/11/2012,"After conducting an audit of the narcotic medication logs; it was discovered that there were an unusual doses of narcotic PRN medications administered to five specific residents. Upon investigation, Reported Perpetrator 2 (RP2) admitted that he/she diverted approximately 40 narcotic PRN medications from Residents #1-#5. RP2 is found responsible for the theft of narcotic medications, constituting abuse. The facility failed to provide a safe medication system and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +RD132215,50R349,RCF,11/26/2011,"The facility failed to provide a safe medication administration system and failed to adequately monitor Resident #1. Resident #1 experienced a significant medication overdose that contributed to his/her fall with injury. The facility failed to immediately notify the local SPD office of this incident. The facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD146698,50R349,RCF,3/17/2014,"Reported Perpetrator 2 (RP2) admitting to taking narcotic pain medication, confirmed by facility security cameras. RP2 is responsible for the theft of narcotic medication which constitutes financial exploitation. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BO148580,50R349,RCF,6/6/2014,"On 6/6/14, Resident #1 had gotten approximately $385 from the bank and sometime that evening it went missing. Interviewed staff had no awareness of the missing money. The facility installed security cameras and refunded him/her the money. It was determined an unknown individual is responsible for the theft of Resident #1's money which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BC150635,50R350,RCF,3/7/2015,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Both residents have been involved in previous altercations and have exhibited behaviors. The facility failed to implement adequate interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB116739,50R351,RCF,4/11/2011,"Resident #1 and Resident #2 had a history of verbal exchanges. Resident #1 has expressed intimidation at Resident #2's aggressive behavior. The facility failed to address behaviors or interventions on either residents' service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB120644,50R351,RCF,7/22/2012,Resident #1 experienced unconsciousness and lost bowel/bladder control. The facility failed to contact the facility RN or 911 for appropriate consultation after the resident experienced a significant change of condition. Resident #1 was later transported to the hospital for treatment by Witness #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB120994,50R351,RCF,9/6/2012,"Resident #1 experienced right side paralysis and required medical attention. The facility failed to timely contact the facility RN or 911 for appropriate direction resulting in the delay in medical attention. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +RB133600,50R351,RCF,6/6/2013,"Witness #2 and Witness #3 had Resident #1 placed in a closet in the kitchen as a ""joke."" Facility administration was aware of the situation but failed to appropriately respond until after a local office complaint came in. The facility failed to ensure Resident #1 was treated with respect and dignity. The failure is a violation of Oregon Administrative Rules.",2,,,, +RB135103,50R351,RCF,11/16/2013,"Resident #1 tried to leave the facility three separate times on 10/31/2013, 11/04/2013, and 11/11/2013. Resident #1_x001A_s service plan was not updated to address his/her elopement attempts. On 11/18/2013 Resident #1 left the facility and was noted to be walking towards the freeway. The facility failed to assess and intervene when Resident #1 exhibited additional exit seeking behavior resulting in a potential for serious harm. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB149380,50R351,RCF,11/20/2014,Resident #1 experienced a fall with injury that resulted in transportation to the hospital. Review of Resident #1's care plan showed that the facility failed to update the resident's change in service needs and is a failure of Oregon Administrative Rules. Investigation concluded that Resident #1's fall was not a result of facility failure.,2,,,, +BH104565,50R352,RCF,6/11/2010,Reported Perpetrator 2 (RP2) was observed to have been rude and failed to treat residents with respect and dignity.,2,0,,, +MV105129,50R353,RCF,8/25/2010,Facility staff failed to follow the care plan to report and document Resident #1's behaviors with Resident #2 and Resident #3. This behavior was reported during training on 8/25/10 and interventions were immediately implemented.,2,0,,, +MV117810,50R353,RCF,8/19/2011,The Facility failed to provide a safe medication administration system. Resident #1_x001A_s medication was discontinued without a physician_x001A_s order and he/she did not receive his/her medication for approximately twelve (12) days. Resident #1 was transported to the hospital for treatment.,3,300,,,Neglect +MV118389,50R353,RCF,11/4/2011,Reported Perpetrator 2 was rough with Resident #1 trying to get him/her to take a shower. Resident #1 was noted to have bruises to his/her left arm.,2,0,Not Substantiated,Substantiated,Physical Abuse +MV129000B,50R353,RCF,12/23/2011,"The facility failed to adequately care plan for Resident #1's falls and failed to assess and intervene with interventions when he/she suffered eight falls, five with injury, in one months time. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +MV121631,50R353,RCF,11/15/2012,Reported Perpetrator 2 (RP2) unlocked the door to the outside courtyard after landscapers were finished and he/she forgot to notify staff to lock the gates. Resident #1 eloped from the facility and he/she returned on his/her own to the facility. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,0,0,,, +MV132965,50R353,RCF,4/7/2013,"During a routine medication count, it was discovered that Reported Perpetrator 2 (RP2) failed to administer three doses of Resident #1's antibiotic medication. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.",2,0,,, +MV133251,50R353,RCF,5/16/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #2 grabbed Resident #1_x001A_s arm and kicked his/her leg. A few days later Resident #1 and Resident #2 were involved in another altercation. No injuries were sustained. The facility failed to address Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV133381,50R353,RCF,5/20/2013,It was reported that Reported Perpetrator 2 (RP2) was heard cursing and saying negative things to Resident #1. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MV133667,50R353,RCF,6/30/2013,Resident #1 grabbed Resident #2 by the throat and pinched his/her arm. Resident #1 has shown aggression toward Resident #2 before. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV133528,50R353,RCF,6/16/2013,Resident #1's service plan states he/she has a history of falls. He/she fell sustaining an injury to the back of his/her head. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV133221,50R353,RCF,4/25/2013,Resident #1's medication was changed by the pharmacy from 10 milligrams to 20 milligrams. Resident #1 was given his/her medication for three days without it being noticed that there was a change in milligrams. Resident #1 did not experience harm as a result. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV145728,50R353,RCF,1/12/2014,Resident #1 slapped Resident #2. No injuries were sustained. Resident #1 has a tendency to become agitated. Resident #1 hits at others. There are no interventions in Resident #1's care plan to address his/her behaviors. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV148791,50R353,RCF,10/2/2014,Resident #1 was not receiving assistance with showers or laundry from the facility. The care plan stated Resident #1 was independent with showers. Resident #1's shower in his/her apartment was full of items making it impossible for him/her to shower. The facility failed to care plan Resident #1 for shower assistance. The facility also failed to follow Resident #1's care plan regarding laundry and failed to put interventions in place for refusal of services. The failures are a violation of Oregon Administrative Rules.,2,,,, +MV159936,50R353,RCF,1/15/2015,Resident #1 and Resident #2 were involved in an altercation that almost caused Resident #2 to fall. No injuries were sustained. Resident #1 had a history of aggression. The facility failed to address Resident #1's behavior which exposed residents to harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV153467,50R353,RCF,11/6/2015,"The facility failed to properly assess and timely seek medical attention for Resident #1. Resident #1 fell in his/her room around 2:30 a.m. and was not properly assessed and sent to the hospital until 8:00 a.m. Resident #1 sustained a right hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV153491,50R353,RCF,11/7/2015,Resident #1 was found in Resident #2's room with his/her hand down Resident #2's pants. Resident #1 had a history of inappropriate sexual behaviors and wandering into other resident rooms. The facility failed to care plan appropriately and implement interventions regarding Resident #1's sexual behaviors. The failure is a violation of resident rights and is considered neglect of care resulting in sexual abuse.,3,300,,,Sexual abuse +OR0001029600,50R353,RCF,11/13/2015,,0,,,Substantiated, +BC129456,50R355,RCF,3/6/2012,"Resident #1 has a history of self harming behavior and care planned for safety monitoring and regular room checks. On March 6, 2012, Resident #1 was discovered with a serrated knife and 4""-5"" cut/scratch on her/his abdomen. The facility failed to provide a safe environment resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC133294,50R355,RCF,4/29/2013,"Resident #1 had a full time caregiver and care planned to be on 15 minute checks when the caregiver was on break. On 04/29/13, Resident #1 swallowed some batteries while his/her caregiver was on break. He/she was transported to the hospital, where the batteries were removed. Resident #1 had a history of swallowing batteries and self-harming behaviors. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV152797,50R356,RCF,9/11/2015,Reported Perpetrator 2 (RP2) transferred Resident #1 alone and Resident #1 fell sustaining injury. Resident 1's care plan stated he/she was a two person transfer. RP2 was found responsible for neglect which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +MV152558,50R356,RCF,8/21/2015,"Resident #1 expressed pain when his/her left arm was moved. Two days later extensive bruising was observed on his/her left collarbone and under his/her breasts. Resident #1 was sent to the hospital for x-rays, which were negative. It was unknown how Resident #1 was injured. The facility failed to provide a safe environment. The failure was a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH120088,50R357,RCF,4/20/2012,Resident #1 was missing a PRN (as needed) medication. Resident #2 had a narcotic medication missing. Resident #2 also had a narcotic medication that had been replaced with medications prescribed for Resident #1. The theft of narcotic medications resulted from actions of an unknown individual. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BH121776,50R357,RCF,10/29/2012,The facility failed to administer Resident #1_x001A_s medication according to physician_x001A_s orders. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH135050,50R357,RCF,11/9/2013,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 has a history of agitation and aggressive behavior with staff and other residents. The facility failed to implement interventions to address Resident #1_x001A_s behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH135148,50R357,RCF,11/20/2013,"Resident #1 and Resident #2 were able to elope from the facility and were found ½ mile away. The facility failed to ensure Resident #1 and Resident #1 were safe and secure. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH146846,50R357,RCF,4/15/2014,"Resident #1 had a physician's order for narcotic medication every four hours for pain. Due to a medication error, he/she was given an incorrect dose of narcotic mediation between 4/5/14 and 4/14/14. Resident #1 experienced increased pain. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH148491,50R357,RCF,8/12/2014,Reported Perpetrator 2 (RP2) tried to forcibly pull Resident #1 from a resulting in a fall. Resident #1 was in another resident's room. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BH150395,50R357,RCF,12/11/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Both residents have had prior altercations with other residents. The facility failed to address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH150529,50R357,RCF,12/1/2014,"Resident #1 and Resident #2 were involved in an altercation resulting in Resident #1 falling and sustaining a fractured hip. Resident #1 and Resident #2 were roommates with a known history of altercations between each other. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH150564,50R357,RCF,12/26/2014,"Resident #1 eloped from the locked memory care unit. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +BH164361,50R357,RCF,4/18/2015,Resident #1 and Resident #2 were involved in an altercation. Both residents had a history of aggression and assaulting others. The facility failed to address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM105877,50R358,RCF,9/29/2010,A resident of the Facility failed to receive needed services related to assistance with hygiene. The Facility did not update the resident's service plan with his/her current needs with respect to ADL (activities of daily living) needs.,2,0,,, +MM129305,50R358,RCF,2/2/2012,"Resident #1 had a history of falling out of bed and/or getting up on his/her own. A tab alarm was being used; however, Resident #1 was able to remove it. On 1/18/12, Resident #1 fell from his/her recliner and broke his/her left hip. Resident #1 returned to the facility on January 20, 2012, with physical therapy. No new interventions were put into place. On February 1, 2012, Resident #1 was found on his/her floor and had fractured his/her right hip. The facility failed to put new interventions into place to keep Resident #1 safe. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM134048,50R358,RCF,8/6/2013,"Resident #1 was hospitalized on 07/11/13 and 07/15/13 for being physically aggressive. Witnesses stated Resident #1 was becoming aggressive during personal cares after returning from the hospital. Within two weeks of returning to the facility, Resident #1 punched a peer in the face. The facility failed to address a resident's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM148854,50R358,RCF,8/31/2014,"The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving his/her prescribed pain patch. Resident #1 experienced pain. There was no documentation regarding missing patches and the MAR and Progress notes did not match for 9/21/15. The MAR shows one dose of Morphine was given and the Progress Notes suggest three doses were given. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL105015,50R359,RCF,8/5/2010,"The facility failed to appropriately assess, monitor or implement new interventions for Resident #1 in terms of his/her increased falls. Resident #1 was found in his/her room face down on the floor and suffered bruising to his/her forehead and left eye area.",2,0,,,Neglect +FL117014,50R359,RCF,5/15/2011,"On 5/15/11, Resident #1 became combative with staff while they prepared him/her to leave the facility for a medical appointment. Reported Perpetrator 2 (RP2) attempted to administer PRN medication, Resident #1 resisted and RP2 threw water from a cup at Resident #1's face.",2,0,,, +FL129848,50R359,RCF,4/19/2012,Resident #1 was care planned for staff to remain with him/her at all times while providing toileting assistance due to a potential serious medical condition. Reported Perpetrator 2 (RP2) left Resident #1 on the toilet to care for other residents. He/she got up and fell; sustaining no injuries. RP2 failed to follow the care plan and exposed Resident #1 to potential for harm. The failures are a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Neglect +FL129934,50R359,RCF,4/28/2012,"Resident #1 ""swung"" at Reported Perpetrator 2 (RP2) and then RP2 open handed ""swatted"" Resident #1 on the left outer thigh. RP2 admitted to this physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +FL132034,50R359,RCF,1/2/2013,The facility failed to follow Resident #1's care plan stating staff will assist him/her with showers. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES133049,50R359,RCF,11/2/2012,Resident #1 was not signed into the memory care voluntarily or by a medical POA and did not have a guardian. Resident #1 did not want to be in the memory care facility. Resident #1_x001A_s physician faxed the facility requesting they initiate assessment of Resident #1 for move from memory care back to assisted living. The facility failed to assure Resident #1_x001A_s rights. The failure is a violation of Oregon Administrative Rules.,2,0,,, +FL132622,50R359,RCF,3/11/2013,"Resident #1 fell on 03/07/13, complained of pain, told staff he/she may have broken their arm and requested pain medication. Staff made an appointment to a walk-in clinic for Resident #1 for four days later. The facility failed to have Resident #1 assessed by a medical professional until 3/10/13, when his/her arm became markedly discolored and he/she was transported to the hospital and diagnosed with a fractured bone. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +FL133774,50R359,RCF,7/11/2013,"Resident #2 hit Resident #1 on the head with an assistive device. No injuries were reported. Resident #2 had a history of being aggressive to other residents. The facility failed to properly care plan for Resident #2 following two prior incidents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL134704,50R359,RCF,10/13/2013,"The facility was made aware that Resident #1 was known to attempt independent transfers, despite being a fall risk when he/she was admitted to the facility. Resident #1 fell three times between 09/21/13 and 10/13/13, all falls resulting in injuries; one being a fractured wrist. Reported Perpetrator 2 (RP2) did not implement a system to adequately address Resident #1's fall risk until after the third fall. The facility failed to adequately care plan related to Resident #1's falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 is responsible for neglect of care, which constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +FL134618,50R359,RCF,10/4/2013,"Resident #2 has a history of aggressive behavior and had prior altercations with Resident #1. Resident #1's care plan directed staff to know where the resident is at all times and redirect if near Resident #2. The facility failed to follow the care plan resulting in Resident #2 hitting Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +FL132290,50R359,RCF,1/29/2013,"The facility failed to communicate Resident #1's response to a medication treatment to his/her physician as the physician ordered. Resident #1's condition worsened until the physician was contacted and the treatment was re-initiated. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL146283B,50R359,RCF,3/5/2014,"The facility failed ensure appropriate documentation was completed for a p.r.n. medication administered to Resident #1 for behaviors. During the course of the investigation, it was observed that Resident #1's room was locked. The facility failed to ensure that residents' were not locked out of their respective rooms. The failures are violations of Oregon Administrative Rules.",2,,,, +FL147625,50R359,RCF,6/26/2014,"The facility failed to maintain sufficient number of staff to meet the care needs of residents resulting in neglect. Witness testimony and facility documentation revealed residents were found incontinent and wearing the same clothes for several days. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,400,,,Neglect +FL148148,50R359,RCF,8/9/2014,Reported Perpetrator 2 (RP2) grabbed Resident #1 and held his/her arm. Resident #1 sustained bodily injury and was emotionally affected. RP2 is found responsible for physical abuse. The facility failed to ensure a safe environment and failed to ensure staff reporting. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +FL148010,50R359,RCF,8/1/2014,The facility failed to care plan appropriately for Resident #1's falls and failed to ensure oral care was successfully provided. Resident #1 had continued falls without continued interventions and had a lack of oral care. The failures are a violation of resident rights and Oregon Administrative Rules.,2,,,, +ES147160,50R359,RCF,5/19/2014,"The facility failed to care plan appropriately for Resident #1's falls. He/she had numerous and ongoing falls, some resulting in injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL133332B,50R359,RCF,5/27/2013,The facility failed to follow Resident #1's care plan regarding a specifically name branded lotion. The failure is a violation of Oregon Administrative Rules.,2,,,, +FL147863,50R359,RCF,7/19/2014,"The facility failed to address Resident #1's behavior and failed to implement interventions and care plan to provide a safe environment and protect other residents. Resident #1 had been the aggressor in several resident to resident physical altercations. The facility also failed to report to the local DHS office as required. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +FL147736,50R359,RCF,7/9/2014,"The facility failed to follow Resident #1's care plan for skin checks and reporting, and failed to intervene when he/she developed peri area skin issues. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +FL147862,50R359,RCF,7/22/2014,Resident #1 had prescribed medications and treatments for his/her eye treatment and creams/ointments for various skin issues. The facility failed to provide a safe medication and treatment administration system to ensure Resident #1's proper care. The failure is a violation of Oregon Administrative Rules.,2,,,, +FL149449,50R359,RCF,11/26/2014,"Resident #1 had fallen numerous times within 19 months, with little to no interventions implemented to address his/her falls. The facility attempted to encourage him/her to use the ambulation device, but was not documented in the service plan, and was not consistently followed. On 11/26/14, Resident #1 had a fall resulting in serious injury requiring hospitalization. The facility failed to implement fall interventions and care plan adequately for Resident #1's falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +FL150546,50R359,RCF,11/18/2014,"The facility failed to appropriate address and care plan with interventions regarding Resident #2's behaviors. Resident #2 had altercations with Resident #1 and other residents. The failures are violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +FL151851,50R359,RCF,7/8/2015,"Resident #1's care plan stated staff were to monitor his/her whereabouts while walking around and keep path clear of clutter. Resident #1 went outside and was found on the ground several minutes later, apparently had tripped over a hose. He/she had no injuries. The facility failed to monitor Resident #1 and failed to keep pathways clear. The failures are a violation of resident rights and violate Oregon Administrative Rules.",2,,,, +BC116536,50R360,RCF,3/16/2011,"Resident #1 had physician_x001A_s orders for a routine blood pressure medication every morning and a PRN blood pressure medication in the evening under certain parameters. Resident #1 was administered the evening PRN medication as routine for approximately 36 days before the error was discovered. He/she required two hospital visits and had a very low blood pressure reading upon discovery. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC120177,50R360,RCF,5/5/2012,"The facility failed to ensure appropriate delegation tasks were completed by Reported Perpetrator 2 and also failed to adequately assess Resident #1's medical needs for appropriate medication administration. Resident #1 was administered an incorrect dose of medication and was transported to the hospital for treatment. Reported Perpetrator 2 is responsible for the neglect of care. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,Substantiated,Substantiated,Neglect +BC132917,50R360,RCF,3/16/2013,"Residents #1, #2 and #3 had personal items and/or cash missing. The facility responded appropriately and conducted an investigation. An unknown person is responsible for the thefts of personal property. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +MS117621,50R363,RCF,7/21/2011,Reported Perpetrator 2 spoke inappropriately to Resident #1 after he/she fell.,2,0,,, +MS132312C,50R363,RCF,2/4/2013,Reported Perpetrator 2 (RP2) failed to follow Resident #2's care plan regarding toileting to be patient with him/her and not rush. The facility failed to ensure Resident #2's care plan was followed and the failure is violation of Oregon Administrative Rules.,2,0,,, +MS132312D,50R363,RCF,2/4/2013,Reported Perpetrator 2 (RP2) failed to follow proper protocol regarding rolling a resident side to side for incontinent care instead of picking up a resident. RP2 picked up Resident #3 exposing him/her to potential harm. The facility failed to ensure RP2 followed protocol and the failure is violation of Oregon Administrative Rules.,2,0,,, +MS146798,50R363,RCF,4/15/2014,"The facility failed to ensure staff was properly trained specific to Resident #1's care needs and service plan. Resident #1 was not transferred properly as service planned. He/she was transferred to the hospital and diagnosed with an arm fracture. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,250,,,Neglect +MS151401,50R363,RCF,5/28/2015,"Reported Perpetrator 2 (RP2) did not treat Resident #1 with dignity, respect, and privacy. A video recording device was found in Resident #1's room. RP2 was seen on the video recording, had repositioned the recording device multiple times, and RP2 removed Resident #1's clothing leaving only an adult incontinent product on. RP2's actions are a significant violation of resident rights. The facility failed to ensure a safe environment to protect Resident #1's dignity and the failure violates Oregon Administrative Rules.",3,,,, +DL117734,50R364,RCF,8/10/2011,"Resident #1 was a fall risk and fell on August 8, 2011. RP2 loosely tied a bathrobe belt around Resident #1 while she/he was in her/his wheelchair to prevent falls for approximately 15 minutes. RP2 was counseled on restraint devices. The facility failed to ensure properly use restraint resulting in the potential for harm.",2,0,,, +DL118338,50R364,RCF,10/17/2011,Resident #1 did not receive prescribed medications. Medications were disposed of without being offered. The Medication Administration Record was not being updated to reflect medications were not being given and inaccurately documented as being given when they had not.,2,0,,, +ES116320,50R365,RCF,2/8/2011,RP2 was observed roughly handling Resident #1 resulting in a bruise. Facility failed to ensure Resident #1's Service Plan was being followed.,2,0,Not Substantiated,Substantiated,Physical Abuse +ES105476,50R365,RCF,10/9/2010,"The facility failed to follow Resident #1's service plan resulting in harm to other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES117401A,50R365,RCF,4/27/2011,Resident #1 requires continuous oxygen and Service Plan directs staff to ensure oxygen is on at all times. RP2 went into the dining room and turned Resident #1's oxygen off because she was not using it. The facility failed to follow Resident #1's Service Plan and physician's order resulting in the potential for harm.,2,0,,, +ES117724C,50R365,RCF,8/2/2011,"Resident #3 requested pain medication and Witness #1 notified RP2 between 11-11:30 PM. Because of Resident #3's medication regimen, RP2 requested and received approval from Witness #3 at 11:45 PM. Due to workload, RP2 was unable to administer Resident #3 her/his medication until 12:12 AM. The facility failed to administer Resident #3 medication in a timely manner resulting in unreasonable comfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 was not found responsible for abuse.",2,0,,,Neglect +ES147476,50R365,RCF,6/19/2014,"Resident #1 and Resident #2 engaged in a physical altercation. Witness testimony revealed Resident #2 had a history of agitation and lashing out at others. Facility documentation failed to address Resident #2's behavior. The facility failed to appropriately care plan to address resident's behavior resulting in negative behavior affecting others. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES147799,50R365,RCF,7/14/2014,"Staff observed Resident #1 with symptoms associated with a cerebral vascular accident prior to 8:00 AM on July 14, 2014. Resident #1 was assessed by RP2 at approximately 9:00 AM and transferred to the hospital after paramedics were called at about 12:31 PM. The facility failed to have an appropriate system in place to ensure timely medical treatment. The failures are violations of resident rights, are considered neglect of care and constitute abuse. RP2 was also found responsible for neglect and constitutes abuse.",4,400,Substantiated,Substantiated,Neglect +ES149601,50R365,RCF,12/12/2014,RP2 took inappropriate pictures of two residents. The facility failed to ensure residents were treated with respect and dignity and a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care resulting in serious loss of human dignity and is considered abuse.,3,,Not Substantiated,Substantiated,Neglect +ES152683,50R365,RCF,9/2/2015,"The facility failed to adequately care plan and monitor Resident #1 related to significant weight loss and rash. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH134598,50R366,RCF,9/26/2013,"Witnesses observed Reported Perpetrator 2 (RP2) forcefully holding Resident #1's hands/arms down when Resident #1 became agitated at shower time, resulting in bruising to Resident #1. RP2 also made inappropriate statements to Resident #1. The facility failed to protect Resident #1 from rough treatment. The failure is a violation of Oregon Administrative Rules. RP2 used rough treatment with Resident #1, which constitutes physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +BH153751,50R366,RCF,7/30/2013,"The facility failed to care plan appropriately with interventions related to Resident #1's falls; and failed to follow his/her care plan for scheduled checks. On 7/30/2013, Resident #1 was found in his/her room, suffered a fall, and was diagnosed with a fractured hip. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. + +This Notification of Findings was completed at a later date; therefore a civil penalty was not issued due to the extended period of time between the incident date and processing by the Department.",3,,,,Neglect +BH147531,50R366,RCF,9/23/2013,"On 9/23/13, Reported Perpetrator 2 (RP2) administered Resident #2's medication to Resident #1 in error. Resident #1 was transported to the hospital for treatment. RP2's actions are considered neglect of care which constitutes abuse. The facility failed to ensure a safe medication administration system which violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +MM105893,50R367,RCF,12/9/2010,A resident of the Facility with a known history of aggressive behaviors was documented to a significant number of altercations with other residents. It was determined the Facility was not following interventions listed in the resident's service plan or addressing the resident's aggression.,2,0,,,Neglect +MM116434,50R367,RCF,2/22/2011,"A resident of the Facility who was known to enter other resident rooms entered the room of another resident and had an altercation. Neither resident was injured, however it was determined that staff failed to follow the residents service plan with respect to monitoring the resident and redirecting.",1,0,,, +MM116681A,50R367,RCF,3/1/2011,"It was determined that residents of the Facility were not receiving services as identified in their care plans, creating situations where residents became incontinent and/or experienced unreasonable discomfort. The cause was determined to be directly linked to short staffing.",2,0,,,Neglect +MM116681B,50R367,RCF,3/1/2011,"Facility staff failed to appropriately assess, monitor and ensure the safety of residents who were previously determined to be at risk for falls. As a result of the Facility_x001A_s failures, both Resident #2 and Resident #3 experienced negative outcomes. It was further determined that a lack of staffing resulted in the resident_x001A_s not receiving appropriate care and services. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A sanction is warrented, however report was used to support a License Condition issued on or about August, 25, 2011.",3,,,,Neglect +CO11094,50R367,RCF,8/3/2011,See condition folder,0,0,,,Neglect +MM117288A,50R367,RCF,6/3/2011,"Facility staff failed to adequately assess, monitor and provide necessary care and services to Resident #1, resulting in the resident not receiving needed services and placing the resident at risk of harm. It was determined that Facility staffing was a core issue with respect to Resident #1 not receiving the services he/she required as stated in his/her service plan.",2,0,,, +MM117395,50R367,RCF,6/20/2011,"A resident of the Facility did not receive showering according to his/her care plan. Resident #1 began receiving services that should have been provided by Facility staff through an outside agency to ensure he/she received services stated in his/her care plan. When the resident was discovered to have beginning stages of skin breakdown, Facility staff did not notify the resident's family or physician, however medical interventions were verbally communicated by the Facility RN without a physician's order.",2,0,,,Neglect +MM117608A,50R367,RCF,7/26/2011,"The facility failed to provide appropriate staffing and assess and intervene after Resident #1 experienced multiple falls with injuries. The failures are violation of resident rights, are considered nelgect of care and constitute abuse. A sanction was not issued due to the Condition placed on the facility's license on 8/25/11.",3,0,,,Neglect +MM117608B,50R367,RCF,7/26/2011,"The facility failed to address Resident #1's resistive behavior resulting in poor hygiene. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117609,50R367,RCF,7/17/2011,The facility failed to adequately care plan resulting in a fall with injury that required transportation to the hospital for treatment. A sanction was not issued due to the Condition put on the facility's license on 8/25/11.,3,0,,,Neglect +MM117770,50R367,RCF,8/14/2011,"The facility failed to adequately care plan resulting in continued falls with injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A License Condition was issued on 8/25/11.",2,0,,,Neglect +MM117782,50R367,RCF,8/8/2011,"The facility failed to assess and intervene after Resident #1 experienced a significant change of condition resulting in moderate harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A sanction is warranted but not issued due to the Condition that was placed on the facility's License on 8/25/11.",3,0,,,Neglect +MM117816,50R367,RCF,8/21/2011,"The facility failed to provide adequate staffing resulting in Resident #1 developing a decubitus ulcer from being restrained. The failure is a violation of resident rights, is considered neglect of care and constitute abuse. A Condition was issued on their license on 8/25/11.",2,0,,,Neglect +MM117872,50R367,RCF,7/18/2011,"The facility failed to ensure a safe medication administration system resulting in medical condition worsening from not receiving a prescribed medication. The failure is a violation of resident rights, is considered neglect of care and constitutesa abuse. A License Condition was issued on 8/25/11.",2,0,,,Neglect +MM117928,50R367,RCF,8/22/2011,"Resident #1 had a history of skin break down and required shifting position at least every two hours. The facility failed to follow Resident #1's service plan resulting in skin breakdown. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A license Condition was issued on 8/25/11.",2,0,,,Neglect +MM117634,50R367,RCF,7/6/2011,The facility failed to coordinate with home health and properly plan care prior to admitting Resident #1 to ensure needs will be met resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +MM117873A,50R367,RCF,7/27/2011,"The facility failed to provide oversight and monitoring after Resident #1 experienced a change of condition resulting in at least one fall with injury that required transportation to the hospital for treatment. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A sanction is warranted, however one was not issued due to License Condition issued on 8/25/11.",3,0,,,Neglect +MM117873B,50R367,RCF,7/27/2011,"The facility failed to follow Resident #1's Service Plan resulting in poor continuity of care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A license Condition was issued on 8/25/11.",2,0,,,Neglect +MM117929,50R367,RCF,8/31/2011,"The facility failed to provide a safe medication administration system resulting in Resident #1 being transferred to the hospital for treatment after receiving another resident's medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM117394,50R367,RCF,6/30/2011,The facility failed provide a safe and secure environment result in three residents with cognitive impairments to elope from the facility. The facility failed to follow Resident #2;s Service Plan who had a history of attempting to elope. The failures are violations of OARs. A Condition was placed on the facility's License on our about 8/25/11.,2,0,,, +MM117930A,50R367,RCF,8/23/2011,"The facility failed to appropriately monitor Resident #1's wound resulting in worsening and the discovery of maggots. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A sanction is warranted, however not issued due to the License Condition issued on 8/25/11.",3,0,,,Neglect +MM118107A,50R367,RCF,9/12/2011,"The facility failed to administer Resident #1's eye drops for two days resulting in worsening of the eye. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM118107B,50R367,RCF,9/12/2011,"The facility failed to ensure Resident #1's Service Plan was followed and failed to ensure medications were being administered as ordered. Resident #1 developed a body and ear rash. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117982A,50R367,RCF,9/7/2011,The facility failed to administer medication as ordered requiring outside agency to apply the medication. The facility failed to answer call light in a timely manner resulting in the potential for harm.,2,0,,, +MM118280,50R367,RCF,10/2/2011,"o The facility failed to provide a safe medication administration system resulting in transportation to the hospital due to medication overdose. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +MM117982B,50R367,RCF,9/7/2011,The facility failed to monitor and evaluate Resident #1 and put in interventions after observed choking on food resulting in the potential for harm.,2,0,,, +MM118360,50R367,RCF,10/5/2011,"Resident #1 had a history of aggressive behavior and care planned to keep within sight when agitated. On October 5, 2011, Resident #1 was agitated that evening and hit Resident #2. The facility failed to follow Resident #1's Service plan resulting in minor harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM118361,50R367,RCF,10/19/2011,"Resident #1 had a history of falls and included falling over oxygen tubing. The facility failed to adequately care plan relating to falls resulting in falling over her/his oxygen tubing and sustaining a hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM118662,50R367,RCF,11/29/2011,"Resident #1 was a fall risk and care planned to have a sensor alarm to notify staff when the resident attempts to get up. Resident #1 fell on or about November 29, 2011 resulting in minor injury. Investigation revealed that the sensor alarm did not go off because the batteries were dead. The facility failed to ensure care plan was followed resulting in minor harm to Resident #1.",2,0,,,Neglect +MM129148A,50R367,RCF,2/2/2012,"Resident #1_x001A_s physician ordered him/her to have a bath or shower daily, however, he/she did not receive a bath or shower for approximately 10 days resulting in a rash. Resident #1 was sent to the hospital and a urinalysis was obtained due to unsuccessful attempts by the facility. Resident #1_x001A_s infection went untreated for two weeks due to the facility being unable to obtain one. The facility failed to follow physician_x001A_s orders. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. .",2,0,,,Neglect +MM129148B,50R367,RCF,2/2/2012,"Resident #1 had an altercation with Resident #2 with no injuries. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM128992,50R367,RCF,1/10/2012,"Resident #1 had a history of falls. Resident #1 had a tab alarm that was to be worn at all times and a sensor alarm on his/her bed. On January 10, 2012, Resident #1 was found face down on the floor. His/her alarm was not sounding. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM128990A,50R367,RCF,1/5/2012,Resident #1 was not receiving assistance with showering or toileting from staff. The facility failed to follow Resident #1_x001A_s service plan and failed to put interventions in place for refusal of care. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM128990B,50R367,RCF,1/5/2012,"Resident #1 was not receiving cream on his/her rashers or receiving the treatment protocol for rashers on the Medical Administration Record. The facility failed to follow Resident #1 service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM129306,50R367,RCF,1/31/2012,Resident #2 was found in Resident #1_x001A_s room at the end of the bed undoing his/her pants. Resident #1 had his/her pants off. The facility failed to care plan Resident #2 for inappropriate sexual behaviors from prior facility. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM129526,50R367,RCF,3/3/2012,"Resident #2 had six incidents of aggression, three involving Resident #1, from the beginning of March to April 1, 2012. The facility failed to follow the interim service plans and keep Resident #1 and #2 separated. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM120850,50R367,RCF,7/31/2012,"Resident #1 was found lying outside on the cement. He/she had fallen and complained of left arm pain. Resident #1 was a fall risk and his/her service plan stated he/she was to have staff walk with him/her. Resident #1_x001A_s physician stated Resident #1 needed to be seen the same day. Resident #1 was not taken to the physician until the next day. He/she was diagnosed with a humeral fracture. The facility failed to follow Resident #1_x001A_s service plan and Resident #1_x001A_s physician_x001A_s order. The failures are a violation of resident rights, are considered neglect and constitute abuse.",3,0,,, +CO12127,50R367,RCF,10/30/2012,"The facility failed to evaluate, develop appropriate interventions, monitor and provide an RN assessment. Resident #1 and Resident #4 each lost a severe amount of weight. The facility also failed to provide Ensure to Resident #4 per his/her physician's order. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,,Neglect +MM121662,50R367,RCF,11/17/2012,Resident #1_x001A_s service plan indicates he/she was to wear skin protective gear at all times due to fragile skin issues. Resident #1 was transferred without the skin protective gear and sustained a cut to his/her leg. The facility failed to follow Resident #1_x001A_s care plan resulting in injury. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM121120,50R367,RCF,9/13/2012,Resident #1 and Resident #2 were involved in an altercation. Resident #1 has had numerous altercations and the service plan states he/she is to be monitored and offered necessary guidance for behaviors. Resident #2_x001A_s service plan also states he/she needs to be monitored due to judgment issues. The facility failed to follow Resident #1 and Resident #2_x001A_s service plans. The failures are a violation of Oregon Administrative Rules.,2,0,,, +MM132665,50R367,RCF,3/13/2013,Resident #1 is a two-person transfer with a Hoyer Lift. Two caregivers transferred Resident #1 without using the Hoyer Lift. Resident #1 sustained a laceration on his/her toe. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM133081,50R367,RCF,4/24/2013,Resident #1 was involved in six episodes of verbal and physical aggression toward other residents during a twenty-four day period. Resident #1's service plan did not provide staff with interventions to prevent incidents. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM133123,50R367,RCF,4/29/2013,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Resident #2 was involved in a previous altercation. The facility failed to address Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM133242,50R367,RCF,5/15/2013,Resident #1 has had several instances of aggressive behavior toward other residents. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM133356,50R367,RCF,5/30/2013,"Resident #1 has a history of physical aggression toward other residents. There have been multiple physical altercations with other residents in a short period of time. The facility failed to address Resident #1's behavior and implement new interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,350,Substantiated,Substantiated,Neglect +MM133489,50R367,RCF,6/11/2013,Resident #1 and Resident #2 were involved in two separate altercations. Resident #1 hit Resident #2. There were no injuries. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM133665A,50R367,RCF,6/16/2013,Resident #1 has a history of making sexual comments to other residents and staff and grabbing staff inappropriately. Resident #1 grabbed Resident #2_x001A_s breast while he/she was trying to pass through Resident #1_x001A_s doorway. The facility failed to appropriately service plan Resident #1 for inappropriate sexual behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM133665B,50R367,RCF,6/16/2013,"While trying to intervene between Resident #1 grabbing Resident #2, Reported Perpetrator 2 (RP2) slapped Resident #1_x001A_s hand lightly with three fingers to get him/her to release Resident #2. The facility failed to properly plan Resident #1_x001A_s care and give appropriate interventions to staff. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM133822,50R367,RCF,7/10/2013,"Resident #1 hit Resident #2 on the hands several times with a puzzle box. There have been two other incidents of Resident #1 hitting Resident #2. The facility failed to address Resident #1_x001A_s behavior and properly plan his/her care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM134326,50R367,RCF,9/4/2013,Resident #1 was administered another residents medications. There were no adverse effects to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM134327,50R367,RCF,9/3/2013,"Resident #1 hit Resident #2 across the chest. Resident #1 has a history of becoming angry with and hitting other residents. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM134143,50R367,RCF,8/8/2013,Resident #1 ran his/her walker into Resident #2 repeatedly. Resident #1 has a history of running into others with his/her walker. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM134630,50R367,RCF,10/3/2013,Resident #1 was administered another resident_x001A_s medications. Resident #1 was transported to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM134590,50R367,RCF,9/29/2013,"Resident #1 has a history of aggression toward other residents. Resident #1 grabbed another resident's hands and squeezed them. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM134679,50R367,RCF,10/4/2013,"Resident #1 was not receiving timely assistance to the restroom or with eating. Resident #2 had documented wounds on his/her buttocks and was receiving wound care from Home Health. Both residents had a weight loss of sixteen pounds. It was also reported that staff are often difficult to find for assistance. The facility failed to assess Resident #1 and Resident #2 for a change of condition and service plan accordingly regarding weight loss and continence issues. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +MM134819,50R367,RCF,10/20/2013,Facility staff witnessed an inappropriate sexual event between Witness #11 and Resident #1. Witness #11 had the access code to the facility and was able to enter the front and back doors without facility staff_x001A_s knowledge. A second event between Witness #11 and Resident #1 was witnessed by staff. The facility failed to provide a safe environment for Resident #1 resulting in sexual abuse. The failure is a violation of resident rights and is considered neglect of care resulting in sexual abuse.,3,2500,,,Sexual abuse +MM134813,50R367,RCF,10/20/2013,Resident #1 was found in his/her bed with injuries from an unknown cause. He/she had bruising and was a high risk for falls. There was no indication that Resident #1 had been checked on between 4:45 a.m. and 7:45 a.m. Resident #1_x001A_s care plan states he/she is to have hourly checks. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM135252,50R367,RCF,11/26/2013,Resident #1 was not being changed every two hours after administration of diuretic for six hours. He/she has a pressure ulcer that Home Health has been treating. Reports were also received that call lights are not being responded to in a timely manner. The facility failed to follow Resident #1_x001A_s service plan. The failure is a violation of Oregon Administrative Rules.,2,,,,Neglect +MM145712,50R367,RCF,12/26/2013,"Resident #1 held Resident #2 down while he/she was sleeping and pinched Resident #2's nose. No injuries were sustained. Resident #1 has a history of numerous resident to resident altercations and being aggressive. The facility failed to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM145801,50R367,RCF,1/15/2014,Resident #1 has a long history of altercations and aggression. He/she was involved in an altercation with Resident #2. No injuries were sustained. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM145744,50R367,RCF,12/20/2013,Resident #1 has a long history of altercations and aggression. He/she was involved in an altercation with Resident #2. The facility attempted numerous interventions and attained the services of a behavioral consultant to address Resident #1's behaviors. The facility was unable to accommodate Resident #1. Resident #1 was issued an involuntary move out notice. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM145717,50R367,RCF,12/24/2013,Resident #1 shoved his/her walker into Resident #2's legs because Resident #2 would not move out of the chair Resident #1 wanted. Resident #2 sustained skin tears on his/her legs as a result. Resident #1 had never shoved his/her walker into anyone before. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM121729,50R367,RCF,11/17/2012,Resident #1 sustained a skin tear while being transferred. He/she did not have leg protectors on as stated in the care plan. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM145746,50R367,RCF,1/2/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM146178,50R367,RCF,2/20/2014,Resident #1 appeared with bruising from an unknown cause. Facility staff did not report the bruising. No reports or alerts regarding Resident #1's bruising were on record. The facility failed to investigate an injury from an unknown origin to rule out abuse. The failure is a violation of Oregon Administrative Rules.,1,,,, +MM121757A,50R367,RCF,11/26/2012,Resident #1 was not administered his/her medications as prescribed for two days. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM121757B,50R367,RCF,11/26/2012,Resident #2 was involved in an altercation with another resident. Staff did not intervene for twenty to thirty minutes. The facility failed to address Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM149054,50R367,RCF,10/16/2014,It was reported that an expensive bracelet had been removed from Resident #1's wrist. Due to the clasp Resident #1 was unable to remove the bracelet. Law enforcement discovered that Reported Perpetrator 2 (RP2) had pawned the bracelet. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MM159830,50R367,RCF,1/3/2015,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Resident #1 had a history of being intrusive into others space and giving unwanted hugs. The facility failed to adequately care plan regarding Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM150341,50R367,RCF,1/26/2015,"RV1 had a history of dementia and hallucinations. On January 26, 2015 RV1 rammed h/h walker repeatedly into RV3. RV1's care plan was not updated to address the issue of physical aggressiveness following the incident on January 26, 2015. On February 13, 2015 RV1 slapped RV4 on the arm. The facility failed to appropriately care plan, monitor and intervene rusulting in potential harm to RV4 as well as other residents.",2,,,, +MM148851,50R367,RCF,9/21/2014,Resident #1's care plan was updated to include puree foods. Just days after the care plan was updated Resident #1 was offered food that was not pureed. The facility failed to follow Resident #1's care plan regarding pureed foods. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO11047,50R368,RCF,3/23/2011,"Due to local office concern and substantial number of recent, ongoing investigations as well as recently completed survey, the Department has determined a Condition for Administrative Consultant is warranted effective April 20, 2011.",3,0,,,Neglect +GB105958,50R368,RCF,12/18/2010,Complainant reported RP2 was rough while providing care to Resident #1 and told the resident to shut up. The investigation determined that RP2 was intentionally rough while providing care to Resident #1.,2,0,Not Substantiated,Substantiated,Physical Abuse +GB105823,50R368,RCF,10/17/2010,RP2 left Resident #1 unattended in the common bathroom of the facility and fell resulting in transportation to the hospital for treatment. RP2 was notified that Resident #1 was a fall risk and should not be left unattended. The facility failed to update Resident #1's Service Plan to address she/he was a fall risk.,3,0,Not Substantiated,Substantiated,Neglect +GB116735,50R368,RCF,4/6/2011,"Resident #1 and Resident #2 had a history of physical altercations, Resident #1 was care planned for 15 minute checks and Resident #2 for 2 hour checks. On 4/6/11 and 4/8/11, they were involved in a physical altercation with each other. The facility failed to adequately care plan and provide care to implement interventions to prevent increased behaviors.",2,0,,,Neglect +GB105825,50R368,RCF,11/24/2010,Resident care plans or progress notes were not updated to address skin breakdown. Residents were not receiving adequate care due to short staffing.,2,0,,, +GB116479,50R368,RCF,2/26/2011,The facility failed to adequately address residents' behaviors resulting in resident to resident altercations that required transportation to the hospital for treatment. Incident was used to support a license condition in April 2011.,3,0,,,Neglect +GB116745,50R368,RCF,4/7/2011,Resident #1 experienced significant weight loss and falls. Resident #2 and Resident #3 experienced significant weight loss. The facility failed to assess and intervene resulting in significant weight loss and falls. Information was used to support licensing condition in April 2011.,3,0,,,Neglect +GB129678,50R368,RCF,3/19/2012,"Resident #1 was observed to have a ground level fall at the facility on or about March 18, 2012. Witness testimony and facility documentation revealed Resident #1 experienced significant pain until transported to the hospital on March 22, 2012 for treatment of a hip fracture. The facility failed to appropriately assess and seek timely medical treatment resulting in unnecessary pain and suffering. Both the facility and RP2 was found responsible for neglect of care and constitutes abuse.",3,350,Substantiated,Substantiated,Neglect +GB116338,50R368,RCF,2/6/2011,"Resident #2 had a history of aggressive behavior or physical altercations with other residents. Resident #2 was observed pushing Resident #1 down resulting in transportation to the hospital for an evaluation. The facility failed to appropriately monitor and address Resident #2's behavior resulting in minor harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A License Condition was issued April 20, 2011.",2,0,,,Neglect +GB148126,50R368,RCF,8/6/2014,"Resident #1 returned to the facility after a fall and was placed on hospice. RP2 put an Interim Service Plan (ISP) in place for no food, only clear liquids per her/his understanding of a conversation she/he had with hospice. Resident #1 was denied food when requested for three days. On August 11, 2014, RP2 received verbal clarification from hospice and the ISP was changed to allow soft foods as tolerated. The facility failed to ensure written orders were left with the facility to ensure appropriate care. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for nelgect of care and constitutes abuse.",3,,Not Substantiated,Substantiated,Neglect +GB150815,50R368,RCF,4/6/2015,The facility failed to adequately care plan Resident #1's behaviors resulting in continued negative behavior affecting others and is a violation of Oregon Administrative Rules.,2,,,, +GB150734,50R368,RCF,3/27/2015,"An investigation was conducted after receiving concerns regarding Resident #1's hygiene. Facility documentation and witness testimony revealed the facility failed to consistently provide assistance as care planned resulting in inadequate hygiene. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility also failed to follow Resident #1's medication order related to fiber chews and is a violation of Oregon Administrative rules.",2,,,,Neglect +GB152851,50R368,RCF,9/13/2015,The facility failed to ensure Resident #1's care plan was followed. RP2 was a new staff member and attempted to pick Resident #1 off the floor unsuccessfully. Resident #1 was care planned as a two person transfer. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO11022,50R369,RCF,2/4/2011,,0,0,,, +BC151191,50R369,RCF,2/3/2015,"RP2 received Resident #1's money from her/his personal incidental fund account without providing documentation to verify the money was used for the resident's benefit. The facility failed to ensure a safe environment resulting in the loss of resident funds and is a violation of Oregon Administrative Rules. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BC151634,50R369,RCF,6/15/2015,Resident #1 had a diagnosis related to memory loss and was identified as not safe to leave the facility unsupervised. The facility failed to ensure a safe environment resulting in Resident #1's successful elopement. Resident #1 was returned safely to the facility without harm. The facility also failed to have a memory care endorcement which is a requirement for a locked facility. The failures are violations of Oregon Administrative Rules.,2,,,, +MS120620,50R370,RCF,7/21/2012,"The facility failed to protect Resident #1 from inappropriate sexual contact of actions by Resident #2. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse and constitutes abuse.",3,2500,,,Neglect +MS120861,50R370,RCF,8/20/2012,"Witness 1 left Resident #1's medication unattended in the medication room, which was an area accessible to others, and where staff retrieved their paychecks. Upon Witness 1's return, eight (8) medications pills belonging to Resident #1 were missing. The facility failed to provide a safe medication administration system that prevents theft of medications. The failure is a violation of resident rights, is considered neglect of care and financial exploitation and constitutes abuse.",2,0,,,Financial abuse +MS152825B,50R370,RCF,9/1/2015,"The facility failed to appropriately plan care for Resident #1's toileting and incontinence needs. Resident #1's incontinence briefs were soaked and his/her clothing and appeared very upset. The facility's failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +GP129313,50R371,RCF,2/11/2012,"On 2/11/12, Resident #1 was found on his/her floor mattress at approximately 6:00am; however he/she was not placed back in his/her bed until approximately between 7:00-7:30am. The facility failed to provide respect, dignity and a safe environment to Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +GP120812,50R371,RCF,8/3/2012,Reported Perpetrator 2 (RP2) was physically rough with Resident #1 causing a scratch to his/her skin. RP2 is found responsible for physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +GP135021,50R371,RCF,11/8/2013,"Resident #1's service plan calls for monitoring of Resident #1 when other residents are close to his/her personal space. However, Resident #1 and Resident #2 were unsupervised in the dinning room when Resident #2 entered Resident #1's personal space. An altercation ensued and Resident #1 was hit in the side of the head with a cane causing a lump. The facility failed to insure Resident #1's care plan was followed which is neglect, constitutes abuse, and is a failure of Oregon Administrative Rules.",2,,,,Neglect +GP120768,50R371,RCF,8/8/2012,"Resident #1 has medication to be given every 6 hours and requires facility staff to call the facility administrator prior to giving it. Facility staff have not been contacting the facility administrator prior giving Resident #1 his/her medication, and on one occasion he/she was given the medication with only 4.25 hours between doses. These failures are a violation of Oregon Administrative Rules.",2,,,, +GP146406,50R371,RCF,3/16/2014,Reported Perpetrator #2 grabbed and held Resident #1's wrists and hands. Resident #1 suffered bruising to his/her hand and forearms as a result. Reported Perpetrator #2 was found responsible for rough treatment which constitutes physical abuse. The facility failed to protect Resident #1 from rough treatment which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +GP134559,50R372,RCF,9/29/2013,Resident #1 was left in the bathroom unattended for one and ½ hours. He/she fell sustaining a skin tear. Resident #1's service plan states he/she is a one person assist for transfers on and off the toilet for safety. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +GP151402,50R372,RCF,5/28/2015,"Complainant reported concerns regarding verbal inappropriate behavior by staff. Investigative findings revealed RP2 was verbally inappropriate with residents on multiple occassions. Facility administration was aware of the situation and failed to address it. The failure is a violation of resident rights, is considered neglect of care resulting in verbal abuse. RP2 was also found responsible for verbal abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +OR0000989102,50R372,RCF,8/5/2015,,1,,,Substantiated, +OR0000989103,50R372,RCF,8/5/2015,,1,,,Substantiated, +OR0000989104,50R372,RCF,8/5/2015,,1,,,Substantiated, +WB121549,50R373,RCF,11/3/2012,Resident #1 was discovered missing from a secure facility and was discovered shortly afterwards down the street. The facility failed to provide a safe environment resutling in the potential for harm. The failure is a violation of Oregon Administrative Rules. New implementations were initiated to prevent future elopements.,2,0,,, +CO13022,50R373,RCF,2/6/2013,"Resident #1 was admitted to the facility in 2011 with a diagnosis of dementia. The facility failed to evaluate, monitor and provide specific PRN (as needed) parameters for Resident #1. Resident #1 experienced ongoing, unrelieved pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC117081,50R374,RCF,5/22/2011,"Following a fall at the Facility which resulted in obvious injury to a resident, Facility staff failed to have the resident assessed by the Facility's RN, as he/she was not on site. The resident received medical attention from unlicensed staff for his/her obvious injury, and was placed back in bed. The following day the resident complained of pain and was sent to the emergency room where it was discovered he/she had a fractured hip and a dislocated thumb.",2,0,,,Neglect +BC134255,50R374,RCF,8/26/2013,"Resident #1 was restless and exit seeking within hours of moving in and subsequently eloped from an empty room by pushing out the screen of a window, and was found a few blocks away. Several attempts were made to return Resident #1 to the facility, until an ambulance was called and transported him/her to the hospital. The facility failed to provide a safe environment and failed to ensure that staff responded to the window alarms. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC153410,50R374,RCF,10/31/2015,"Witness testimony revealed Reported Perpetrator 2 (RP2) had been physically abusive to Resident #1, Resident #2 and Resident #3 on more than one occasion. All three residents were care planned having cognitive issues, behaviors and how to work around them. RP2 had not read their care plans and stated that the facility did not have staff read the care plans. Other staff stated that they were not provided time to read the care plans and would have to read on their breaks. The facility failed to ensure staff were properly trained and followed care plans to ensure appropriate care was provided and to ensure resident safety. The failures are a violation of resident rights and violate Oregon Administrative Rules. RP2's actions are considered physical abuse.",3,,Not Substantiated,Substantiated,Physical Abuse +BC132133,50R375,RCF,1/9/2013,Resident #1_x001A_s credit card statement showed unusual charges that he/she did not make. Reported Perpetrator 2_x001A_s (RP2) name was associated with one of the charges and his/her address was associated with another charge. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC152483,50R375,RCF,8/13/2015,The facility failed to protect Resident #1 from rough treatment. Resident #1 was pushed down onto his/her bed. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC164237,50R375,RCF,12/29/2015,Resident #1 was punched and sustained a skin tear. An unknown individual was found responsible for physical abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +HB151091B,50R376,RCF,4/28/2015,The facility did not follow up with the pharmacy and/or physician after a medication was changed on the electronic MAR and the facility did not have a corresponding prescription to match. The facility failed to ensure a safe medication administration system resulting in Resident #1 being administered the wrong dose of medication. There was no negative outcome as a result of the error and the failure is a violation of Oregon Administrative Rules.,2,,,, +BH132600,50R377,RCF,3/6/2013,"Resident #1 was care planned to have a bed alarm in use due to the risk of falls. Staff removed the bed alarm and did not use it. Resident #1 fell and sustained a broken hip. The facility failed to follow Resident #1's care plan resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH146794,50R377,RCF,4/15/2014,"On or about April 15, 2014, Resident #1 was found agitated in another resident's room and was guided back to her/his room by RP2. RP2 was observed to kick Resident #1 approximately three times after being kicked by the resident. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +BC118200A,50R378,RCF,9/28/2011,"Resident #1 had injuries that were not medically assessed, were treated without medical orders and RV_x001A_s doctor was not notified. Failed to evaluate and refer to RN.",2,0,,, +BC118200B,50R378,RCF,9/28/2011,There is no physician_x001A_s order to refuse Resident #1 second helpings of meals. The facility cook served residents undercooked chicken which was replaced with properly cooked chicken but served on the same plates. The facility failed to assure food safety.,2,0,,, +BC129636B,50R378,RCF,3/20/2012,"Resident #1_x001A_s call light string broke at least four times during the month of March. When the call light is inoperable, Resident #1 has to have his/her room door open and call out for help. Resident #1 prefers to keep his/her room door closed. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC120479,50R378,RCF,7/8/2012,Resident #1 wanted his/her ears pierced. Reported Perpetrator 2 (RP2) pierced Resident #1_x001A_s ears. A few days later Resident #1_x001A_s left ear became infected. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO12104,50R378,RCF,9/7/2012,"The findings of the Residential Care Facility Re-licensure Survey completed on April 11, 2012, and two revisit surveys completed on July 2, 2012 and September 7, 2012, determined that the Facility continues to be out of substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility_x001A_s noncompliance placed residents at risk for harm. The failures are a violation of Oregon Administrative Rules.",2,0,,,Neglect +BC121305,50R378,RCF,10/2/2012,Resident #1 refused his/her medications from 10/2/12 _x001A_ 10/10/12. The facility did not notify Resident #1_x001A_s physician of his/her refusal. The facility did not discover the problem until it was time to re-order Resident #1_x001A_s medications. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC120952,50R378,RCF,7/16/2012,"Resident #1_x001A_s care plan is out of date and he/she is not consistently repositioned during the night per the physician_x001A_s order and care plan. There is no documentation regarding Resident #1 refusing to be changed and repositioned. The facility failed to follow Resident #1_x001A_s care plan and his/her physician_x001A_s orders. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC121080,50R378,RCF,8/30/2012,Resident #1 was prescribed blood sugar medication at his/her previous facility. His/her discharge instructions from the previous facility included orders for Resident #1 to take blood sugar medications. Resident #1 had not been given blood sugar medications since moving into the new facility. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121698,50R378,RCF,11/20/2012,Resident #1 was in pain and requested transfer from his/her wheelchair to bed. Resident #1 is a two person transfer. He/she is care planned to be up for a maximum of two hours. The request was made at 10:00 a.m. and caregivers were not available to transfer him/her until 11:25 a.m. The facility failed to assist Resident #1 with transfer in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121753,50R378,RCF,11/18/2012,"Resident #1 entered the facility with physician_x001A_s orders to self-medicate. The facility RN reassessed Resident #1 and found that he/she was able to self-medicate. Resident #1 is prescribed Tylenol and self administers the medication. Reported Perpetrator 2 (RP2) gave Resident #1 Tylenol and he/she felt they had to take it. Resident #1 had no adverse reaction. The facility failed to document or record, investigate or report the incident. The failures are a violation of Oregon Administrative Rules.",2,0,,, +BC121661,50R378,RCF,10/31/2012,Reported Perpetrator 2 (RP2) was assisting Resident #1 with personal care. Resident #1 became aggressive with RP2 and hit RP2 on the arm. RP2 hit Resident #1 on the arm or shoulder area in response. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +BC132109A,50R378,RCF,4/1/2012,Resident #1_x001A_s dentures were lost. There was nothing in the care plan to address Resident #1_x001A_s behavior of placing the dentures in a tissue and leaving them in his/her bed. There was no indication that the facility attempted to assist him/her in replacing the dentures. The facility failed to document Resident #1_x001A_s report of the missing dentures. The facility also failed to amend Resident #1_x001A_s care plan to address the lack of dentures and his/her dietary needs after the dentures were lost. The failures are a violation of Oregon Administrative Rules.,2,0,,, +BC132109B,50R378,RCF,4/1/2012,The facility completed an informal investigation regarding Resident #1_x001A_s missing dentures. There was no incident report or progress notes regarding Resident #1_x001A_s lost dentures. The facility failed to report to APS regarding the loss of Resident #1_x001A_s property. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC146828,50R378,RCF,4/10/2014,The facility failed to administer Resident #1's medication according to physician_x001A_s orders. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO14203,50R378,RCF,9/26/2014,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed on September 26, 2014 (DTF512).",3,,,,Neglect +BC147999,50R378,RCF,6/25/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. There had been previous arguments between Resident #1 and Resident #2. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC149203,50R378,RCF,9/28/2014,Resident #1 received a new order for antibiotics to be administered four times per day for ten days. Resident #1 did not receive three doses of the ordered medication. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC150221,50R378,RCF,2/7/2015,Resident #1 did not receive his/her pain patch as prescribed on 2/7/15. The facility lacked documentation regarding an emergency supply that was sent to the facility. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO15077,50R378,RCF,4/6/2015,"The facility failed to provide effective administrative oversight regarding residents_x001A_ quality of care and services as evidenced by the first re-visit survey (#WWCE12) findings completed on May 29, 2015.",3,,,,Neglect +BC150706,50R378,RCF,3/24/2015,"Physician_x001A_s orders for Resident #1, Resident #2 and Resident #3 were not followed in a timely manner. The facility failed to provide a safe medication administration record. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC150967,50R378,RCF,3/31/2015,Resident #1 received 5mg of his/her prescribed medication instead of 10mg on approximately seven occasions. Resident #1 did not experience any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC151128,50R378,RCF,4/16/2015,Resident #1 was not administered his/her scheduled 4:00 a.m. pain medication. The Medication Administration Record showed it had been administered. Resident #1 did not suffer any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC151130,50R378,RCF,4/23/2015,Resident #1 had a medication change and started exhibiting behaviors soon after. On 4/2/15 Resident #1 was involved in an altercation with Resident #2. Two days later he/she was involved in an altercation with Resident #3. The facility failed to implement interventions for Resident #1's increased behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS128903,50R379,RCF,1/11/2012,"Resident #1 eloped from the facility when another resident_x001A_s family member opened the front door and allowed Resident #1 to exit. Law Enforcement returned Resident #1 to the facility unharmed. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rule.",2,0,,, +MS129010,50R379,RCF,1/20/2012,"Resident #1 had a history and diagnosis of bowel problems. Bowel movements were documented and monitored by staff. Resident #1 had gone 11, 10 and 6 days without a bowel movement being recorded. The facility failed to monitor and notify Resident #1_x001A_s physician. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS129987,50R379,RCF,4/25/2012,"On April 25, 2012, Resident #1 was having difficulty standing. While assisting him/her to the shower, Resident #1 collapsed to his/her knees. Resident #1 was taken to his/her physician on April 27, 2012, where the physician advised that Resident #1 be taken to the emergency room. An x-ray showed that he/she had a fractured pelvis. Resident #1 had a significant change of condition due to not being able to ambulate. The facility failed to properly assess and obtain timely medical treatment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +MS121112A,50R379,RCF,9/17/2012,Resident #1_x001A_s narcotic pain medication was missing. It was concluded the medication was inadvertently pulled for destruction and destroyed due to errors. The facility failed to provide a system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS132158,50R379,RCF,1/17/2013,"Resident #1 has a history of being resistive to showering. While assisting Resident #1 with a shower, Resident #1 was screaming and trying to bite. Reported Perpetrator 2 (RP2) covered Resident #1_x001A_s mouth with a towel and his/her hand. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +MS132537,50R379,RCF,2/23/2013,Resident #1 is cognitively impaired. A witness heard Reported Perpetrator 2 (RP2) yell at Resident #1 and use profanity. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MS133270,50R379,RCF,5/18/2013,Resident #2 physically assaulted Resident #1 due to the lights being on in the bathroom. Resident #1 and Resident #2 are roommates. Resident #1 sustained bite marks and scratches. Resident #2 had a history of verbal aggression toward Resident #1 and staff. No changes to Resident #2_x001A_s service plan or interventions were implemented regarding his/her behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS133975,50R379,RCF,8/1/2013,"Resident #1 was a fall risk and had several falls with no new interventions made to his/her service plan. Resident #1 also lost a significant amount of weight. The facility failed to adequately update Resident #1's service plan to address fall interventions and weight loss. The facility failed to assess, care plan and appropriately monitor after significant changes of condition. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS133627,50R379,RCF,6/25/2013,Two witnesses heard Reported Perpetrator 2 (RP2) being verbally inappropriate to Residents #1 and #2. RP2 was counseled previously for being verbally inappropriate to residents. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for verbal abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MS134677,50R379,RCF,10/10/2013,"Resident #2 had a history of aggressive and combative behaviors, and was wandering into other residents' rooms. Resident #2 and Resident #1 had an altercation in Resident #1's room and Resident #1 sustained an arm fracture. The facility failed to adequately monitor Resident #2. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS135440,50R379,RCF,12/20/2013,It was reported that Reported Perpetrator 2 (RP2) made an inappropriate comment to Resident #1 while changing his/her incontinent garment. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS145960,50R379,RCF,2/3/2014,Resident #1 required full assistance. He/she requested assistance and no one came. His/her family member had to provide assistance to Resident #1. The facility failed to timely respond to Resident #1's call for assistance. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS135070,50R379,RCF,11/4/2013,"The facility received an order to administer pain and anxiety medication. The facility failed to follow the order resulting in Resident #1 experiencing pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility is on a current condition (RCFCD14-012) a civil penalty will not be issued.",3,,,,Neglect +MS146994,50R379,RCF,5/6/2014,"Resident #1 required full assistance for all transfers and was non-ambulatory and non-weight bearing. He/she had five falls during a short period of time, with no amendments to his/her service plan. He/she fell on 4/28/14 and was not transported to the hospital until 5/2/14. Resident #1 was admitted to the hospital for pain and a hip fracture. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS147207,50R379,RCF,5/27/2014,"Resident #1 had several falls and incidents of aggression between February 27, 2014 and May 8, 2014. Resident #1 sustained multiple skin tears. The facility failed to appropriately care plan to address fall interventions and address Resident #1's aggressive behavior. The failures are a violation of Oregon Administrative Rules.",2,,,, +CO14154,50R379,RCF,8/12/2014,"The Facility failed to provide effective administration oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed August 14, 2014 (#L3MB11).",3,,,,Neglect +MS147636,50R379,RCF,7/4/2014,Resident #1 was found unattended in the courtyard. Outdoor temperatures were reaching over 90 degrees that day. It was unknown how long he/she had been in the courtyard. His/her temperature was 99 degrees and he/she was red and perspiring. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS134760,50R379,RCF,10/16/2013,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 has had previous altercations. Resident #2 can be combative and verbally threatening and has also exhibited inappropriate sexual behaviors. Resident #2 Resident #1 both sustained scratches and bruising. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS145586,50R379,RCF,1/3/2014,Resident #1's service plan states he/she is a fall risk. Resident #1 was found on the floor of his/her room. Resident #1 sustained an abrasion on his/her forehead. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS147945,50R379,RCF,7/29/2014,Resident #1's service plan stated that he/she was a fall risk. He/she has had multiple falls without the service plan being updated regarding falls. Resident #1 fell while unsupervised in the courtyard sustaining a skin tear to his/her forearm. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS148127,50R379,RCF,8/11/2014,"Resident #2 had a history of entering other resident's rooms uninvited. He/she entered Resident #1's room. Resident #1 told Resident #2 to get out and he/she refused. Resident #1 hit Resident #2 in the abdomen. No injuries were sustained. The facility failed to implement interventions to address Resident 2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148182A,50R379,RCF,8/13/2014,"Resident #1 had a history of wandering into other resident's rooms. + +Resident #2 had a history of yelling at people to get out of his/her room and then pushing them. Resident #1 was found on the floor outside Resident #2's room. Resident #1 was sent to the hospital and received six stitches to his/her elbow. The facility failed to implement interventions to address Resident 2's behavior. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility is on a current condition (#RCFCD14-012) a civil penalty will not be issued.",3,,,,Neglect +MS148182B,50R379,RCF,8/13/2014,"Resident #1 had a history of falls. Resident #1 had 25 falls between 2/3/14 and 8/13/14. Seventeen of the falls resulted in injury. The facility failed to adequately update Resident #1's service plan to address fall interventions. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility is on a current condition (#RCFCD14-012) a civil penalty will not be issued.",3,,,,Neglect +MS147363B,50R379,RCF,6/12/2014,Resident #1 requires full assistance with medication and treatment management. Resident #1 had a physician's order to have cream applied topically daily to the affected area. The facility failed to follow Resident #1's physician's orders to apply cream daily. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS148413,50R379,RCF,9/5/2014,"Resident #1 was a fall risk and experienced multiple falls within the facility. Falls resulted in skin tears and bruising. No incident report was found for skin tears obtained on 8/24/14 or 9/2/14. The fall on 9/1/14 was caused by an altercation with another resident not by RV misusing his/her walker. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148415,50R379,RCF,9/5/2014,"Resident #1 was verbally aggressive toward Resident #2 since he/she moved into the facility on 8/5/14. Resident #1 and Resident #2 were roommates and involved in an altercation. Resident #1 sustained a bruise to his/her face from Resident #2 hitting him/her. Resident #1 continued to be verbally aggressive toward Resident #2 even after Resident #2 was moved to another room. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148581,50R379,RCF,9/17/2014,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 had a history of being physically aggressive toward other residents and staff. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,, +MS147808A,50R379,RCF,7/18/2014,"Resident #1 had a history of falls and was a fall risk. Resident #1 sustained approximately thirty-seven falls between February 14, 2014 and July 14, 2014. Resident #1 sustained an additional ten falls for which incident reports were not supplied. Resident #1 sustained skin injuries from the falls. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS147808B,50R379,RCF,7/18/2014,"Resident #1 had a history of inappropriate sexual behaviors that were identified in a behavior assessment done prior to him/her moving into the facility. The assessment also recommended that Resident #1 be placed in a facility with his/her same gender. The facility failed to appropriately service plan Resident #1 for inappropriate sexual behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS148809A,50R379,RCF,10/7/2014,"Resident #1 and Resident #2 were involved in multiple physical and verbal altercations while they were roommates at the facility. Resident #1 and Resident #2 were placed in separate rooms. Resident #1 continued to go into Resident #2's room and have altercations with Resident #2. The facility failed to implement adequate interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148809B,50R379,RCF,10/7/2014,"Resident #1's medication was increased to help address behaviors. The increase in medication increased Resident #1's inability to ambulate. Resident #1 had five falls at the facility between August 7, 2014 and September 12, 2014. The September 12, 2014 fall resulted in Resident #1 injuring his/her back. Facility failed to update Resident #1's care plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148809C,50R379,RCF,10/7/2014,"Resident #1's physician and psychiatrist recommended alternate placement to another facility for him/her. The facility was conducting a 90 day evaluation instead of finding alternate placement for Resident #1as recommended by his/her physician. Resident #1 continued to have aggressive behaviors toward facility residents. The facility failed to perform adequate assessment of Resident #1 and care plan accordingly. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148809D,50R379,RCF,10/7/2014,"Resident #1 had sexually inappropriate behaviors toward female facility staff and female residents. Resident #1 goes into other resident's rooms and tries to get in their beds. The facility failed to care plan appropriately regarding Resident #1's sexual behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148445,50R379,RCF,9/3/2014,"Resident #1 was a fall risk and experienced multiple falls within the facility. Falls resulted in skin tears, bruising and abrasions. The facility failed to adequately update Resident #1's service plan to address fall interventions in a timely manner. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148564,50R379,RCF,9/10/2014,"The facility was aware that Resident #1 was a fall risk and had a history of getting up without assistance. Resident #1 sustained 33 falls during a 60 day period. Safety checks were scheduled for 1 - 2 hours per the care plan. The care plan was not modified to increase safety checks or supervision to prevent falls and negative behavior incidents. The facility failed to adequately update Resident #1's care plan to address fall interventions and negative behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS149003,50R379,RCF,10/22/2014,Resident #1 and Resident #2 were found together in Resident #2's room several times. The facility failed to appropriately care plan regarding Resident #1 and Resident 2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS148439,50R379,RCF,9/5/2014,"The facility was aware that Resident #1 was a fall risk and had a history of getting up without assistance. Resident #1 sustained multiple falls that resulted in skin tears, bruising and abrasions. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +MS148810A,50R379,RCF,10/7/2014,"Resident #1 continued to experience falls and increased behaviors toward staff and other residents. The care plan was not modified to increase safety checks or supervision to prevent falls and negative behavior incidents. The facility failed to adequately update Resident #1's care plan to address fall interventions and negative behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS149355,50R379,RCF,11/25/2014,"Resident #1 and Resident #2 both had a history of physical aggression toward each other as well as other residents. Resident #1 and Resident #2 were involved in a prior altercation with each. Resident #1 pushed Resident #2 down causing Resident #2 to sustain bruising. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS159797,50R379,RCF,1/5/2015,"Resident #2 had a history of aggression. Resident #1 sustained a large bruise due to Resident #2 grabbing his/her arm. Resident #3 did not sustain any injury from being grabbed by Resident #2. Resident #1 was care planned to have a caregiver with him/her 24 hours per day. The facility failed to follow Resident #1's care plan to provide supervision 24 hours per day until another placement was found. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148412,50R379,RCF,8/23/2014,"Resident #1 had a history of behaviors including resident to resident altercations, aggressiveness toward staff and one witnessed incident of punching and slamming against exit doors. The facility failed to implement adequate interventions regarding Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS148414,50R379,RCF,9/1/2014,"Resident #1 fell while attempting to self-transfer. He/she sustained a skin tear. The facility had been using a tab alarm for Resident #1, but he/she was able to remove it. The facility failed to update Resident #1's care plan to reflect the change in placement of his/her tab alarm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS149273,50R379,RCF,11/17/2014,Resident #2 and Resident #1 were involved in an altercation. Both residents have a history of being physically aggressive. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS149590A,50R379,RCF,12/13/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. These residents have a history of not getting along. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS149590C,50R379,RCF,12/13/2014,Resident #5 and Resident #6 were involved in an altercation. No injuries were sustained. These residents had a history of prior issues. The facility failed to address Resident #5 and Resident #6's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS149590D,50R379,RCF,12/13/2014,Resident #1 and Resident #7 were involved in an altercation. No injuries were sustained. Resident #1 had a history of aggressive behavior toward staff and residents. The facility failed to implement adequate interventions regarding Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS149590E,50R379,RCF,12/13/2014,"Resident #1 and Resident #8 were involved in an altercation. No injuries were sustained. Resident #1 had a history of aggressive behavior toward staff and residents and has had numerous altercations. The facility failed to implement adequate interventions regarding Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS149590F,50R379,RCF,12/13/2014,"Resident #1 and Resident #9 were involved in an altercation. No injuries were sustained. Resident #1 had a history of aggressive behavior toward staff and residents and has had numerous altercations. The facility failed to implement adequate interventions regarding Resident #1_x001A_s behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS149701B,50R379,RCF,12/26/2014,"Resident #1 was witnessed inappropriately touching Resident #2. The same day Resident #1 had inappropriate touching incidents that involved Resident #3, Resident #4 and Resident #5. The facility failed to put immediate interventions into place for Resident #1's inappropriate sexual behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS159908,50R379,RCF,1/13/2015,"Resident #1 slapped Resident #2. Resident #1 had a history of aggressive behavior and numerous altercations. The facility failed to implement adequate interventions regarding Resident #1's behavior. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition (RCFCD14-012) a civil penalty will not be issued.",3,,,,Neglect +MS149433,50R379,RCF,12/3/2014,"Resident #1 had a history of falls and was a fall risk. Resident #1 sustained numerous falls with injury between September 28, 2014 and November 30, 2014. Resident #1 sustained injuries from the falls. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition (RCFCD14-012) at the time of the incident a civil penalty will not be issued.",3,,,,Neglect +MS150108A,50R379,RCF,2/3/2015,"Resident #1 hit Resident #2 in the face. No injuries were sustained. Resident #1 had a history of agitation. The facility failed to implement adequate interventions to address Resident #1's behaviors. The failure is a violation resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS150108B,50R379,RCF,2/3/2015,Resident #4 was involved in an altercation with Resident #3. No injuries were sustained. The facility failed to adequately address Resident #4's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS159955,50R379,RCF,1/16/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained a cut to his/her forehead. Both residents have been involved in prior incidents. The facility failed to adequately address Resident #1 and Resident #2's behaviors. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition (#RCFCD14-012) a civil penalty will not be issued.",2,,,,Neglect +MF150073A,50R379,RCF,1/27/2015,"Resident #1 does not have a concept of personal space. Resident #1 bumped into Reported Perpetrator 2 (RP2) when attempting to get to a chair. RP2 blocked Resident #1 until he/she said ""excuse me"". Resident #1 showed signs of agitation after the incident. The facility failed to assure Resident #1's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MF150073B,50R379,RCF,1/27/2015,"Resident #1 does not have a concept of personal space. Resident #1 bumped into Reported Perpetrator 2 (RP2) when attempting to get to a chair. RP2 blocked Resident #1 until he/she said ""excuse me"". RP2 was witnessed stating something to the effect of ""if you push me again we will have a problem"". Resident #1 showed signs of agitation after the incident. The facility failed to assure Resident #1's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS150295,50R379,RCF,2/18/2015,Resident #1 had a history of inappropriate sexual behaviors. Resident #1 was found kissing Resident #2. The facility failed to adequately care plan Resident #1 for inappropriate sexual behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS148930,50R379,RCF,9/18/2014,"Resident #1 and Resident #2 were involved in an altercation. Both residents sustained skin injuries. Both residents have a history of physical aggression toward other residents. The facility failed to implement adequate interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS150277,50R379,RCF,2/13/2015,"Resident #1 had a history of aggressive behavior toward other residents and staff. Resident #1 and Resident #2 were involved in an altercation. The facility failed to implement interventions to address Resident #1's behaviors. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition (RCFCD14-012) at the time of the incident, a civil penalty will not be issued.",3,,,,Neglect +MS150692,50R379,RCF,3/24/2015,"Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Both residents have a history of physical altercations. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS147796,50R379,RCF,7/17/2014,"Resident #5 had a history of touching opposite gender residents inappropriately. There were numerous incidents of Resident #5 sexually touching opposite gender residents with no interventions being put into place to prevent incidents. The facility failed to appropriately care plan Resident #5 for inappropriate sexual behaviors. The facility also failed to appropriately train staff regarding residents with dementia. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,2500,,,Neglect +MS148081,50R379,RCF,8/6/2014,"Resident #1 had a history of being physically aggressive toward staff and residents. Resident #1 was involved in a number of altercations. Resident #2 refused to sleep in his/her room due to being afraid of Resident #1 since Resident #1 was his/her roommate. The facility failed to implement interventions to address Resident #1_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS150504,50R379,RCF,3/10/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 had a history of aggressive behaviors and had been involved in numerous altercations with other residents and staff. The facility failed to put appropriate interventions in place for Resident #2_x001A_s behaviors. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition (condition #RCFDC14-012) a civil penalty will not be issued.",2,,,,Neglect +MS150368,50R379,RCF,2/25/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 had a history of aggressive behaviors and had been involved in numerous altercations with other residents and staff. The facility failed to put appropriate interventions in place for Resident #2's behaviors. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility was on a condition (condition #RCFDC14-012) a civil penalty will not be issued.",2,,,,Neglect +MS150970,50R379,RCF,4/14/2015,Resident #1 had a history of aggressive behaviors. Resident #1 was involved in several altercations within a short period of time on the same day. No injuries were sustained. The facility failed to implement appropriate interventions to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS151113,50R379,RCF,4/30/2015,Resident #1 and Resident #2 were involved in an altercation. Resident #1 had a history of altercations with other residents. Resident #1 pushed Resident #2 and he/she fell. Resident #2 reopened a skin tear from a previous fall. The facility failed to implement appropriate interventions to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MF151378,50R379,RCF,5/20/2015,Resident #2 was involved in an altercation with Resident #1 when Resident #1 entered Resident #2's room. Resident #2 had a history of behaviors toward other residents. Resident #2 is care planned to have his/her door closed and other residents are to be directed away from him/her. The facility failed to follow Resident #1's care plan resulting in an altercation. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS150811,50R379,RCF,4/6/2015,Resident #1 had a medication change and started exhibiting behaviors soon after. On 4/2/15 Resident #1 was involved in an altercation with Resident #2. Two days later he/she was involved in an altercation with Resident #3. The facility failed to implement interventions for Resident #1's increased behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS151055,50R379,RCF,4/24/2015,Resident #1 and Resident #2 were involved in an altercation. Both residents have a history of being combative and aggressive. No injuries were sustained. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS151083,50R379,RCF,4/24/2015,"Resident #1 and Resident #2 were involved in an altercation on 4/24/15. + +Resident #3 and Resident #4 were involved in an altercation on 4/24/15. + +Resident #3 and Resident #5 were involved in an altercation on 4/28/15. + +All residents involved had previous history of behaviors. The facility failed to appropriately address Resident #1, #2, #3, #4 and #5's behaviors. + +The failure is a violation of Oregon Administrative Rules.",2,,,, +MS151121,50R379,RCF,4/30/2015,"Resident #1 and Resident #2 were roommates. Resident #2 required full assistance for mobility. Resident #1 had a history of aggressive behaviors and was possessive of Resident #2. Resident #1 repeatedly fought facility staff trying to protect Resident #2 which upset Resident #2. No service plan adjustments were made for Resident #1's behaviors. The facility failed to provide a safe environment for Resident #2 and failed to implement interventions to address Resident #1's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,400,,,Neglect +MS151331,50R379,RCF,5/3/2015,"Resident #1 had increasing behaviors. He/she was involved in at least four altercations with Resident #2 between April 6, 2015 and May 17, 2015. Resident #2 has also had increasing behaviors. The facility failed to implement appropriate interventions to address Resident #1's and Resident #2's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS151120A,50R379,RCF,4/30/2015,"Resident #2 exhibited increased behaviors after medication changes. Resident #2 was involved in altercations with Resident #1, Resident #3 and Resident #4. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS151120B,50R379,RCF,4/30/2015,Resident #2 and Resident #3 were not administered prescribed medications due to the facility not having the medications available. The facility failed to administer medications as ordered. The failure is a violatin of Oregon Administrative Rules.,2,,,, +MS151120C,50R379,RCF,4/30/2015,"Resident #3 experienced numerous falls at the facility, one resulting in injury. The facility documented on serveral occasions that the falls were due to medication changes. The facility failed to perform adequate screening or assessment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MF151556,50R379,RCF,6/10/2015,Reported Perpetrator 2 (RP2) was involved in an altercation with Resident #1. RP2 checked Resident #1's incontinent brief while he/she was sleeping. He/she does not wear one and is not incontinent. Resident #1 became agitated and got out of bed and attacked RP2. RP2 pushed Resident #1 back onto the bed. No injuries were sustained. RP2 did not read the service plan and was not given enough time to review it. The facility failed to report the incident to APS. The facility also failed to provide appropriate training to staff. The failures are a violation of Oregon Administrative Rules.,2,,,, +MS150780,50R379,RCF,4/2/2015,"Resident #2 was involved in altercations with Resident #1, #3, #4 and #5. Resident #2 had a history of aggressive behaviors and altercations with other residents. The facility failed to provide a safe environment for residents and failed to implement appropriate interventions to address Resident #2's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,400,,,Neglect +MS151519,50R379,RCF,6/8/2015,"The facility failed to properly assess Resident #1 for a change of condition and obtain timely medical treatment. Resident #1 was found unresponsive in the courtyard. Resident #1 was not taken to the hospital. Family took Resident #1 to the hospital on 6/14/15 and he/she was treated for a burn injury and skin infection. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS151852,50R379,RCF,7/9/2015,"Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) forcefully changed Resident #1's brief and clothing. No injuries were sustained. RP2 and RP3 were found responsible for physical abuse. The facility failed to protect Resident #1 from physical abuse and appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Physical Abuse +MS152185,50R379,RCF,7/23/2015,"Resident #1's medication was not administered according to his/her physician's order. Resident #1 was sent to the hospital. The facility failed to provide a safe medication administration system and appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,, +MS151774,50R379,RCF,7/1/2015,"Resident #1 was involved in altercations with Resident #2 and Resident #3 on the same day. Resident #1 had a history of behaviors toward other residents. The facility failed to implement appropriate interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,400,,,Neglect +MS151816,50R379,RCF,7/2/2015,"Resident #1 pushed Resident #2 down resulting in injury to Resident #2. + +The facility failed to provide a safe environment for residents and failed to implement appropriate interventions to address Resident #1's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS151735,50R379,RCF,6/26/2015,"Resident #1 was found in his/her bed in the morning by a caregiver in pain. The RN stated Resident #1 did not fall and that he/she could not have gotten out of bed without assistance. A portable x-ray was ordered and Resident #1 was found to have a left hip fracture. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS152731,50R379,RCF,9/5/2015,"Resident #2 and Resident #1 were involved in an altercation on August 31, 2015 and again on September 5, 2015. The latest altercation resulted in both residents sustaining skin injuries. Resident #2 had a history of altercations and aggressive behavior. The facility failed to implement interventions to address Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS152940,50R379,RCF,9/28/2015,"Resident #1 and Resident #2 were involved in an altercation. + +Resident #1 sustained a skin injury. Resident #2 had a history of aggressive behaviors. The facility failed to implement interventions to address Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS153016A,50R379,RCF,10/2/2015,Resident #1 had multiple falls while at the facility. It was discovered by hospital staff that Resident #1 had an unexplained discolored skin injury on his/her inner thighs. The cause of the discolored skin injury was unknown. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS153016B,50R379,RCF,10/2/2015,"On 9/22/16, Resident #1's physician ordered his/her CBGs be checked for a few weeks. Resident #1's CBGs were not checked from 9/25/15 through the morning of 9/29/15. Resident #1 was sent to the hospital on 10/1/15 due to him/her being lethargic and non-responsive. The facility failed to follow a physician's order. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MF153207,50R379,RCF,10/17/2015,"Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) were witnessed physically removing Resident #1 from another cottage. Resident #1 was watching television and not causing any issues. Resident #1 sustained skin injuries, was crying and visible upset due to being physically forced to leave the cottage. RP2 and RP3 were found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +MS152799,50R379,RCF,9/10/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 hit Resident #1 causing a skin tear. Both residents had a history of inappropriate behaviors. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS152896,50R379,RCF,9/23/2015,Resident #1 appeared with a skin tear on his/her left forearm from an unknown cause. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS152802,50R379,RCF,9/11/2015,"Resident #1 grabbed Resident #2's arm when he/she was trying to enter Resident #1's room. Resident #2 sustained a bruise on his/her arm. Resident #2 had a history of entering other resident rooms. The facility failed to put interventions in place regarding Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS152035,50R379,RCF,7/13/2015,"Resident #1 had several incidents of being sexually inappropriate with Resident #2, Resident #3, Resident #4 and Resident #5. The facility failed to care plan appropriately and implement interventions regarding Resident #1's sexual behaviors. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse.",3,300,,,Sexual abuse +MS153682,50R379,RCF,11/24/2015,"Resident #1 pinched Resident #2 causing bruising. Resident #1 had a history of altercations with other residents. Resident #2 did not have a history of altercations. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS153669,50R379,RCF,11/23/2015,"Resident #2 pushed Resident #1. Resident #2 had a history of aggressive behavior. No injuries were sustained. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS154001,50R379,RCF,12/21/2015,"Resident #1 was involved in altercations with Resident #2 and Resident #3. Resident #1 had a history of going into other resident rooms and having altercations with the other residents. Resident #2 sustained injury do to Resident #1 biting him/her. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS153130,50R379,RCF,10/11/2015,"Resident #2 entered Resident #1's room. Resident #1 grabbed him/her causing a skin tear. Resident #2 and Resident #1 had a history of behaviors. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS153758,50R379,RCF,11/30/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 sustained a skin tear. Resident #2 and Resident #1 had a history of behaviors. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO14110,50R380,RCF,5/16/2014,"The facility failed to allow Resident #1 the right to refuse service. Resident #1 was placed in a standing frame for HHPT (Home Health Physical Treatment). The resident expressed refusal through non-verbal cues, however continued to receive the treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB121001,50R381,RCF,8/31/2012,Reported Perpetrator 2 (RP2) inappropriately discontinued Resident #1's medication. Resident #1 did not receive his/her medication for approximately seven (7) days. No medical intervention was necessary and he/she had no negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB121280,50R381,RCF,10/2/2012,"The facility failed to follow Resident #1's care plan to ensure the sensor alarm was turned on while he/she was in the recliner. He/she was found on the floor with injuries including a bruise on left elbow and a cut on nose, but no broken bones. The sensor alarm for the recliner was not on. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB132001X,50R381,RCF,12/26/2012,"The facility failed to maintain a safe medication administration system. Resident #1 did not receive his/her medication for 9 days resulting in his/her condition worsening. Upon treatment, his/her condition improved. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB152032,50R381,RCF,7/13/2015,"Resident #1 was slapped on his/her bare leg by Reported Perpetrator #2(RP2), which is considered physical abuse. The facility failed to protect Resident #1 which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +HB151345,50R381,RCF,5/21/2015,Reported Perpetrator #2 (RP2) grabbed Resident #1 by the jaw and yelled inappropriate language at him/her. RP2 is responsible for verbal abuse. The facility failed to ensure a safe environment for Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HB120204,50R382,RCF,6/4/2012,"Resident #2 had a history of wandering into other residents_x001A_ rooms. + +There were two altercations between Resident #1 and Resident #2. The second altercation resulted in both residents being on the floor and Resident #2 sustaining a cut to his/her head. The facility failed to adjust Resident #2_x001A_s care plan to address his/her wandering into other residents_x001A_ rooms. The failure is a violation of Oregon Administrative Rules",2,0,,, +HB120465,50R382,RCF,7/10/2012,Resident #1 and Resident #2 both have a history of aggression. There were two altercations involving Resident #1 and Resident #2. Resident #1 sustained skin tears in both incidents. The care plans for Resident #1 and Resident #2 were not updated after the incidents and no new interventions were put into place. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB132026X,50R382,RCF,1/2/2013,"Resident #1 had dementia and was a fall risk and had fallen several times in the facility. Resident #1 fell in his/her room on July 8, 2013, and was transported to the hospital. The facility did not have an incident report or a formal investigation report for Resident #1's fall. The facility failed to adequately update Resident #1's service plan to address fall interventions. SPD also did not receive a self-report from the facility for Resident #1's fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB132686,50R382,RCF,3/2/2013,"Resident #1 had started vomiting late the night of 3/1/13. Resident #1 was vomiting, weak, had a fever and was saying ""help me! help me!"" to the care givers. Resident #1 continued to decline. Paramedics were called when Resident #1 became non-responsive on the morning of 3/2/13. The facility failed to assess for a change of condition and obtain timely medical treatment for Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB146587,50R382,RCF,4/3/2014,"Resident #1 has been involved in numerous altercations with other residents. Resident #1 enters the rooms of other residents without permission and becomes aggressive when asked to leave. The facility failed to implement adequate interventions regarding Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB147200,50R382,RCF,5/27/2014,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 has a history of aggressive behavior toward other residents. The facility failed to implement interventions to address Resident #2's behaviors and aggression that resulted in injury to Resident #1. Resident #1 was transported to the hospital. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB148638,50R382,RCF,9/22/2014,"Resident #1 had bruising from an unknown cause. The facility failed to appropriately care plan Resident #1 regarding toileting and changing of incontinent products which resulted in Resident #1 being left too long in soiled garments and developing a rash. The facility also failed to follow Resident #1's care plan regarding leaving his/her door open to lessen his/her anxiety. Facility staff shut his/her door resulting in anxiety for Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB149186,50R382,RCF,11/7/2014,"Resident #1 was discovered with a large bruise on the inside of his/her left thigh, which caused him/her pain. Resident #1's care plan stated that facility staff were to notify the MA or RN of any skin breakdown. The bruise was not reported to the MA or RN. The origin of Resident #1's bruise was unknown. No interventions were put into place regarding Resident #1's tendency to self-transfer/toilet. The facility failed to appropriately care plan Resident #1 for his/her needs. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB149174A,50R382,RCF,11/6/2014,"Resident #1 moved to the facility due to him/her being a fall risk and needing increased monitoring and assistance. Resident #1 was found on the floor in his/her room from an apparent fall. Resident #1 sustained a head injury and was transported to the hospital. The facility failed to follow Resident #1's service plan resulting in injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB150169,50R382,RCF,2/5/2015,"Resident #1 required a one-person assist in the shower. Staff were assisting him/her when Resident #1 fell. He/she was put back into bed and no one was notified that Resident #1 had fallen. On the same day, Resident #1 fell in the courtyard and was sent to the hospital. Resident #1 sustained a hip fracture and facial trauma. The facility failed to adequately assess and intervene when Resident #1 sustained several falls. The facility also failed to appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB151948B,50R382,RCF,7/10/2015,"It was reported that various pills were found in resident rooms. The pills were found on the floor, the bed and in the garbage. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB152657A,50R382,RCF,8/19/2015,"Resident #1 experienced several falls during a five month period. Resident #1 fell again on 8/13/15 which caused a hip fracture. The facility failed to assess Resident #1 for a change of condition and care plan accordingly. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB152657C,50R382,RCF,8/19/2015,"Staff noticed that Resident #1 had skin break down on his/her heels. Home Health recommended hourly position changes. Resident #1's heels worsened and he/she was transported to the hospital due to infection. The facility failed to care plan for Resident #1's skin breakdown. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH133162,50R383,RCF,4/30/2013,Facility staff discovered that Resident #1's narcotics were missing from the locked medication room. The theft of narcotic medications resulted from an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BH134518,50R383,RCF,9/21/2013,"The facility failed to appropriately care plan for Resident #1's known falls and failed to implement new interventions after falls. Resident #1 suffered bruising and a rib fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH134728,50R383,RCF,10/10/2013,"Resident #1 was noted to have an injury on his/her shoulder on 10/10/13 and did not appear new; however there was no documentation of an injury prior to this date. The facility failed to monitor Resident #1's change of condition and implement interventions needed. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH134729,50R383,RCF,10/12/2013,"The facility failed to provide a safe environment and failed to have functioning door alarms to alert staff. Resident #1 was found in the courtyard and had fallen and suffered a head wound and was transported to the emergency room. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,400,,,Neglect +BH146760,50R383,RCF,4/9/2014,"The facility failed to adequately monitor and assess Resident #1 when his/her condition changed. Resident #1 suffered several injuries of unknown origin as a result. These failures are considered neglect of care, constitute abuse, and are violations of Oregon Administrative Rules.",2,,,,Neglect +BH147341B,50R383,RCF,6/1/2014,"Reported Perpatrator #2 failed to sit Resident #1 at an angle protecting Resident #1's legs from other residents, as was specified in Resident #1's care plan. Resident #1 suffered bruising to his/her knee as a result of another resident bumping Resident #1 with their lower extremities. Reported Perpetrator #2 failed to follow Resident #1's care plan which is considered neglect of care and constitutes abuse. The facility failed to insure facility staff followed Resident #1's care plan, this failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +BH148895,50R383,RCF,10/9/2014,Reported Perpetrator 2 was observed pinching Resident #1's ankle. Resident #1 screamed in pain and developed a bruise in the area where the pinching took place. Reported Perpetrator #2 was found responsible for physical abuse. The facility failed to protect Resident #1 from physical abuse. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BH153499,50R383,RCF,2/15/2015,Resident #2 had been care planned to not be allowed with Resident #1 in an unsupervised environment. Resident #2 was observed to be with Resident #1 in the facility hallway. This failure is a violation of Oregon Administrative Rules.,2,,,, +BH147551,50R383,RCF,1/19/2014,Reported Perpetrator #2 (RP2) failed to ensure the gait belt he/she was using to assist Resident #1 with a transfer was tight enough. Resident #1 fell during transfer and sustained bruising from the loose gait belt. RP2 is responsible for neglect of care which constitutes abuse. The facility failed to ensure a safe environment for Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +MV121613A,50R385,RCF,11/13/2012,"Shortly after Resident #1 moved into the facility, he/she showed signs of exit seeking. On 11/10/12, he/she showed W2 and W6 how he/she could open his/her windows wider by removing the side guards, resulting in staff securing his/her windows. On 11/13/12, Resident #1 walked into an unoccupied room, removed the side guards off one window, which allowed the window to open wide enough for him/her to leave the building. Resident #1 was found by local law enforcement and was transported to the ER for evaluation and was returned without injury. The facility failed to ensure a safe environment and failed to update his/her service plan when it was noted that he/she exhibited exit seeking behaviors. The failures are a violation of Oregon Administrative Rules.",2,0,,, +MV121613B,50R385,RCF,11/13/2012,"On 11/10/12, RP2 changed Resident #1's agitation medication from PRN every 6 hours if needed to scheduled every 8 hours without physician's orders. RP2 faxed the request to change on 11/10/12 but the physician did not approve the request and fax new orders until 11/19/12; 9 days later. RP3 then made further errors by changing it back to every 6 hours if needed; wrote the wrong date down; and wrote in he/she was to receive the medication at 8am, 2pm, and 8pm even though the medication was to be given as needed. The facility failed to obtain a medical order before changing Resident #1's medication from PRN to scheduled. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO13040,50R385,RCF,4/4/2013,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the initial licensure survey findings completed on April 4, 2013.",3,0,,,Neglect +MV133445,50R385,RCF,6/9/2013,"Resident #2 had three incidents of being found in bed with an opposite sex resident. The facility failed to provide a safe environment and failed to adequately care plan for Resident #2_x001A_s behaviors. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse and constitute abuse.",3,2500,,,Sexual abuse +MV134669A,50R385,RCF,10/10/2013,"The facility failed to ensure Resident #1's service plan was followed, such as: repositioning, changing, showering, or using precautions of hand washing and wheelchair brake setting for transfers. The failures are a violation of Oregon Administrative Rules.",2,,,, +MV134669B,50R385,RCF,10/10/2013,Resident #1's family purchased items/supplies for staff to use for his/her care; however it was discovered that the some supplies were removed from his/her room. The facility failed to provide a safe and homelike environment and the failure is a violation of Oregon Administrative Rules.,2,,,, +MV134596,50R385,RCF,9/12/2013,"While Reported Perpetrator 2 (RP2) provided care to Resident #1, he/she hit RP2 and RP2 replied stating he/she will hit back if Resident #1 hits RP2. RP2 is found responsible for verbal/emotional abuse. The facility failed to ensure Resident #1 was treated with respect and dignity and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MV147077,50R385,RCF,5/14/2014,Reported Perpetrator 2 (RP2) gave Resident #1 another residents medications. He/she was monitored and did not have any adverse signs or symptoms. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.,2,,,, +MV147797,50R385,RCF,4/29/2014,The facility failed to ensure adequate hygiene. Resident #1 was noted to have a rash. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV150319,50R385,RCF,2/17/2015,Resident #1 had been on alert for increased agitation and anger from 1/28/15-2/19/15. There were two separate altercations on 2/13/15 and 2/17/15 where Resident #1 was the aggressor. Resident #2 was grabbed by the jaw and right arm. The facility failed to appropriately care plan to implement effective interventions regarding Resident #1's increased agitation and anger. The failure created an unsafe environment and is considered neglect of care and constitutes abuse.,2,,,,Neglect +MV150320,50R385,RCF,2/17/2015,"Resident #1 was admitted 2/14/15 and care plan noted that he/she had random outbursts of anger. On 2/16/15 and 2/17/15, he/she had physically aggressive anger behaviors against staff. On 2/18/15, he/she had erratic behaviors and locked himself/herself in Resident #2's room. Resident #1 eventually opened the door and Resident #2 was not harmed. Resident #1 was transported to the hospital pending evaluation. The facility failed to implement effective interventions to provide a safe environment for all residents and staff. The failure exposed them to potential harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV152586,50R385,RCF,8/17/2015,Resident #1 was not administered his/her medications as ordered. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.,2,,,, +OR0000996801,50R385,RCF,8/24/2015,,0,,,Substantiated, +MV164510,50R385,RCF,1/29/2016,"On 1/24/16, Resident #1 and Resident #3 were not administered their 8am medications. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC146123,50R389,RCF,2/17/2014,"Resident #1 was care planned for assistance in ambulating at least twice a day. Witness testimony and facility documentation revealed Resident #1 was not receiving services as care planned, resulting in poor continuity of care. The facility failed to follow Resident #1's Care Plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD134738,50R390,RCF,7/26/2013,"Resident #1 and Resident #2 were involved in an altercation resulting in Resident #1 falling. Resident #1 sustained a head wound and was transported to the hospital. The facility failed to implement interventions to address Resident #2's aggressive behaviors that had been demonstrated prior to this incident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD135205,50R390,RCF,10/16/2013,The facility failed to have a safe medication administration system resulting in Resident #1 not receiving prescribed medications. Resident #1 did not experience any harm as a result. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD135280,50R390,RCF,12/3/2013,"Resident #2 reported that Resident #1 had punched him/her. Resident #1 sustained a skin tear to his/her left hand and Resident #2 sustained a skin tear near his/her mouth. Resident #1 had a history of agitation and striking other residents and staff. Resident #1 was not being monitored by staff. The facility failed to implement interventions to address Resident #1_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BO146138,50R390,RCF,2/12/2014,Resident #1 was involved in an altercation with Resident #2. Resident #1 is easily angered by other residents. No injuries were sustained. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD146777,50R390,RCF,3/23/2014,Resident #1 was involved in an altercation with Resident #2. Resident #1 had a previous altercation. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO148333,50R390,RCF,7/28/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO150476,50R390,RCF,2/9/2015,Resident #1 was involved in an altercation with Resident #2. Resident #1 had been involved in previous altercations. No injuries were sustained. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +EN149392,50R391,RCF,11/15/2014,"Reported Perpetrator 2 (RP2) made statements to Resident #1 regarding him/her not being able to move to the assisted living side of the facility due to him/her not being able to care for him/herself enough. Resident #1 was found after his/her exchange with RP2, crying and visibly upset. Resident #1 also stated he/she had nightmares and felt his/her choice was being taken away. RP2 was found responsible for emotional abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HB134553,50R393,RCF,9/27/2013,"In September 2013 Resident #1 was able to leave the facility through an alarmed exit door. Resident #1 sustained a fall while outside the facility causing some abrasions to his/her face. The alarm system on the door was found to no longer work which allowed Resident #1 to leave the facility without tripping the alarm. The facility failed to maintain a functional alarmed exit door. This failure is considered neglect of care, which constitutes abuse, and is in violation of Oregon Administrative Rules.",2,,,,Neglect +CO14085,50R395,RCF,4/17/2014,"Facility failed to provide effective administrative oversight based on the initial licensure survey completed on April 17, 2014. See survey for specific details. Order Imposing License Condition issued on May 7, 2014 for ROA and RN Consultant after informal conducted on May 6, 2014 at 2:00 PM.",3,,,, +MV149530,50R395,RCF,12/8/2014,"Resident #1 was a fall risk that required a one person assist with transfers. Resident #1 was assisted by staff and sustained a fall when being assisted off the bed. The fall mat was under the bed. The facility failed to adequately provide clear directions to staff related to the fall mat. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 was not found responsible for abuse.",2,,,,Neglect +MS146803A,50R400,RCF,4/17/2014,"The facility failed to provide a safe medication administration system resulting in Resident #1 missing medication for two weeks. Resident #1 suffered vomiting and diarrhea as a result and was treated at a hospital for dehydration. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +MS146803C,50R400,RCF,4/17/2014,Resident #2 and Resident #3 were on alert charting requiring close supervision and to maintain separation from the other. On or around 04/24/14 Resident #2 and Resident #3 were observed to be seated in the same common area with no facility staff providing close supervision. The facility failed to follow the service plan for Resident #2 and Resident #3. This failure is a violation of Oregon Administrative Rules.,2,,,, +MS146803D,50R400,RCF,4/17/2014,"Reported Perpetrator #2 failed to follow facility training and protocol and picked Resident #1 and carried him/her to their room to remove them from the dining room. Reported Perpetrator #2 is responsible for neglect of care which constitutes abuse. The facility failed to a safe environment, which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +MS148461A,50R400,RCF,9/9/2014,"The facility failed to stop Resident #1 from leaving the facility without assistance. Resident #1 was able to leave the facility without assistance having been let out by facility staff. This failure is considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS148461B,50R400,RCF,9/9/2014,The facility failed to maintain a safe medication administration system. Witness 5 was picking up Resident #1's medication and was given another residents medication by mistake. Facility staff were able to stop Witness 5 from administering the wrong medication to Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,,, +MS147701,50R400,RCF,7/11/2014,"The facility failed to adequately intervene when Resident #1 experienced side effects associated with a medication change. Resident #1 sustained severe weight loss over the course of 3 months. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS149019,50R400,RCF,10/23/2014,"The facility failed to adequately monitor and intervene related to Resident #2's aggression towards other residents. Resident #2 and Resident #1 were in an altercation, and Resident #1 sustained bruises and a skin tear. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +MS151102,50R400,RCF,4/28/2015,"The facility failed to adequately monitor Resident #1 who had a history of aggressive behavior towards others. Resident #2 also had a history of being aggressive if others were being aggressive towards him/her. Resident #1 and Resident #2 got into an altercation and both residents sustained bruising. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BH147303,50R401,RCF,5/26/2014,"Resident #1 was care planned as a two person assist with transfers. On or about May 26, 2014, RP2 was asked to assist Resident #1 to the restroom. Resident #1 was unable to bear weight and RP2 assisted the resident to the floor resulting in hip pain. Witness testimony revealed RP2 was not familiar with this resident and was unaware that she/he was a two person transfer. The facility failed to provide a safe environment and ensure Resident #1's care plan was followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO14222,50R402,RCF,9/19/2014,"The facility failed to evaluate, monitor, and ensure a RN assessed and intervened when Resident #3 experienced a significant change of condition. Resident #3 developed a pressure sore to his/her left foot and a sore to his/her bottom. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +CO15006,50R402,RCF,12/4/2014,"The facility failed to monitor Resident #6 consistent with his/her evaluated needs and service plan related to falls. Resident #6 experienced harm due to on-going falls with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES152125,50R402,RCF,7/12/2015,"Resident #1 had a history of falls while wandering, however there were no documented fall interventions or instructions for staff. Reported Perpetrator 2 (RP2) took Resident #1's walker and placed it out of his/her reach and was restricted to his/her walker. The facility failed to implement interventions to reduce falls and failed to care plan instructions for staff. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +OR0001044101,50R402,RCF,12/24/2015,,0,,Not Substantiated,Substantiated, +AL147684,50R403,RCF,5/7/2014,Resident #1 exited the courtyard by using the emergency exit push bar on the gate. Staff responded to alarm and directed Resident #1 back inside. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL152806,50R403,RCF,3/28/2015,"The facility failed to adequately monitor Resident #1. Resident #1 was to be monitored and redirected if attempting to wander into other residents rooms. He/she wandered into Resident #2's room and an altercation ensued where Resident #2 sustained a bruise on his/her hand. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +AL151947,50R403,RCF,2/19/2015,The facility failed to adequately provide a safe environment. Resident #1 had a history of exit seeking behavior and was able to elope from the facility. This failure is a violation of Oregon Adminstrative Rules.,2,,,, +MV153435,50R404,RCF,11/3/2015,The facility allegedly failed to provide care to meet resident's needs. An investigation determined no facility wrongdoing occurred.,0,,,, +MS152718,50R407,RCF,7/30/2015,It was reported that Resident #1 had a diamond necklace missing. Reported Perpetrator 2 (RP2) admitted to taking the necklace. RP2 was found responsible for the theft of Resident #1's necklace which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +CO15004,50R408,RCF,11/10/2014,"The facility failed to ensure a Registered Nurse (RN) assessed and documented findings in order to develop appropriate interventions for Resident #2 and Resident #3 who experienced significant changes of condition. Resident #2 eloped twice with no interventions being developed. Resident #3 experienced a fall resulting in a fracture and developed a stage two pressure ulcer. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BA159757,50R408,RCF,11/20/2014,"Resident #1, Resident #2 and Resident #3 require assistance with toileting. The facility failed to assist with toileting in a timely manner resulting in incontinence. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA159767A,50R408,RCF,11/19/2014,Resident #1 was not administered his/her over the counter medications for approximately one week. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA159767B,50R408,RCF,11/19/2014,"Resident #1 moved into the facility on November 21, 2014. He/she had a physician's order for compression socks and compression boots. He/she did not have compression socks available for at least a two week period. The facility failed to properly plan care as they were not aware of the physician's order. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA159767C,50R408,RCF,11/19/2014,Resident #1 did not receive a shower for approximately one week. He/she had an exception for three showers per week. After it was brought to staff attention Resident #1 received a shower. The facility failed to follow Resident #1's care plan to provide three showers per week. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA159791A,50R408,RCF,12/4/2014,"Resident #1 was prescribed pain patches that were to be changed every seventy-two hours. Resident #1 was found with old pain patches still on, in addition to the new pain patches. Resident #1 exhibited increased drowsiness. The facility failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA159791B,50R408,RCF,12/4/2014,Resident #1 was not being administered his/her pain and anxiety medications as prescribed and according to his/her service plan. Several doses were not administered. Resident #1 was to be awakened if he/she was asleep to administer medication per his/her service plan. The facility failed to administer medication as ordered and failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA159791C,50R408,RCF,12/4/2014,"Resident #1 was prescribed a protein pump inhibitor medication that was to be administered by the facility. Resident #1 did not receive this medication from November 4, 2014 to December 5, 2014. The facility failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA159808,50R408,RCF,12/11/2014,"Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA150048A,50R408,RCF,11/26/2014,"The facility was responsible for ordering and administering Resident #1's medications. Resident #1 was missing between twelve and sixteen narcotic pain medications. An unknown individual was found responsible for the theft of Resident #1's medication which constitutes financial exploitation. The facility failed to provide a medication system that prevents theft or misuse of medications. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BA150048B,50R408,RCF,11/26/2014,"Resident #1's medications were not being administered by the facility according to physician's orders. Resident #1 experienced unreasonable discomfort. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA150699,50R408,RCF,3/21/2015,"Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA150755,50R408,RCF,1/21/2015,Resident #1 did not receive a medication for approximately two days. The medication had been misfiled. Resident #1 did not experience a negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA151746,50R408,RCF,5/1/2015,Resident #1 and Resident #2 missed a dose of medication due to the facility not having it available. Neither resident experienced any adverse effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA151581,50R408,RCF,1/20/2015,Resident #1 was not administered four doses of a prescribed morning medication. Resident #1 did not experience any adverse reaction from the medication error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,300,,, +WB148265,50R409,RCF,7/27/2014,"Resident #1 was a known fall risk and experienced three injury falls between June and July 2014. The facility failed to adequately monitor and care plan surrounding Resident #1_x001A_s falls resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +WB149285,50R409,RCF,11/15/2014,Resident #1 resided in a secure memory care facility and successfully eloped. The facility failed to ensure a safe environment resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +WB150459,50R409,RCF,2/28/2015,"Resident #1 was improperly transferred by two caregivers after a gait belt was unable to be located. The facility failed to ensure Resident #1's care plan was followed resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +WB152488,50R409,RCF,8/12/2015,The facility failed to ensure a safe medication administration system resulting in 6 missing narcotic from Resident #1's discontinued medications. The failure is a violation of Oregon Administrative Rules.,2,,,, +OT150325,50R412,RCF,1/9/2015,"The facility failed to provide a safe environment and prevent Resident #1 from eloping. Resident #1 was a known risk for elopement, and He/she was able to get out of the facility again. This failure is a violation of Oregon Administrative Rules.",2,,,, +OT150469,50R412,RCF,2/4/2015,"Resident #1 had medication taken from the med room. The medications were taken by an Reported Perpetrator #2, and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,,Substantiated, +OT150563,50R412,RCF,2/23/2015,The facility failed to provide a safe medication administration system. Resident #1 was given a PRN medication 3 hours early. This failure is a violation of Oregon Administrative Rules.,2,,,, +OT150602,50R412,RCF,2/15/2015,The facility failed to administer one of Resident #1's medications as ordered. He/she was given the wrong dose of one of his/her medications. This failure is a violation of Oregon Administrative Rules.,2,,,, +BC151818,50R413,RCF,5/18/2015,"The facility failed to ensure Resident #1 was adequately checked and received timely medical treatment after experiencing a significant change of condition. Resident #1 was transported to the hospital and diagnosed with a stroke. The failures are violations of resident rights, is considered neglect of care and constitute abuse. RP2 was also found responsible for neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +MV150539,50R414,RCF,3/9/2015,The facility is a secure memory care community and failed to ensure a safe environment after three (3) residents successfully eloped from the building on different occasions. Residents were discovered shortly after elopement and were returned unharmed. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV151389,50R414,RCF,5/19/2015,"Resident #1 had a history of agitated and aggressive behavior. The facility failed to adequately monitor Resident #1 with behaviors resulting in Resident #2 being hit. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV153627B,50R414,RCF,11/14/2015,The facility failed to ensure a safe medication administration system resulting in Resident #1 not receiving an ordered medication. The failure is a violation of Oregon Administrative Rules.,2,,,, +OR0000997900,50R414,RCF,8/31/2015,,0,,,Substantiated, +MV154027,50R414,RCF,12/17/2015,"On or about December 17, 2015 the pharmacy delivered RV1's pain medication to the facility. RV1 had already moved from the facility so RV1's pain medication was placed in the medication return box. RV1's pain medication was taken by an unknown individual and this person is responsible for theft of medication, which is considered financial exploitation and constitutes abuse. The facility's failure is a violation of the Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +DA153824B,50R415,RCF,12/3/2015,"On 8/20/15, Resident #1 was not administered his/her medication as ordered. The facility failed to ensure a safe medication administration system and the failure violates Oregon Administrative Rules.",2,,,, +MM152955B,50R416,RCF,9/20/2015,Reported Perpetrator 2 (RP2) helped pass medications. When medications were passed the Med Aides were signing the Medication Administration Record that they had administered the medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC152122,50R417,RCF,7/10/2015,"Resident #1 reported a wallet containing $130 was reported missing from the resident's room while she/he was at the hospital. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BC152946,50R417,RCF,9/23/2015,The facility failed to ensure a safe environment resulting in the loss of money from Resident #1. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft and is considered financial exploitation.,2,,Not Substantiated,Substantiated,Financial abuse +OR0001025906,50R417,RCF,11/5/2015,,1,,Not Substantiated,Substantiated, +CO15247,510053,AFH,12/4/2015,Substitute Caregiver Criminal Background clearance expired.,3,250,,, +TM132576,510088,AFH,3/3/2013,"It was reported that on or about March 3, 2013, Licensee failed to provide appropriate timely care to Resident #1 when his/her health condition changed. Resident #1 had been experiencing increased behaviors and changes in his/her health condition. Licensee failed to intervene when Resident #1's condition changed and failed to update Resident #1's care plan as his/her condition changed. Licensee's failures are a violation of Oregon Administrative Rules are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +TM150524A,510088,AFH,3/6/2015,"On or about March 10, 2015, the Department received a complaint which alleged the Licensee (RP1) had failed to provide Resident #1 (RV1) and Resident #2 (RV2) with appropriate care and services. RV1_x001A_s Care Plan dated January 28, 2015 documents that facility _x001A_staff to toilet [RV1] every two hours_x001A_. On multiple occasions, home health arrived for a visit and RV1 was found in soiled incontinence wear. RV1 developed significant skin breakdown on his/her buttocks likely due to being left in wet and soiled personal garments. RV2_x001A_s Care Plan dated January 23, 2015 stated staff were to change RV2, if needed and check for bowel movements. It also indicated that caregiver was to turn RV2 every two hours. RV2 was found in soiled incontinence wear by home health nurses on multiple occasions. RV2 experienced skin breakdown that was consistent with being turned infrequently and left in soiled briefs. RP1 acknowledged that she waited to change RV2 on the days home health was expected because it was easier to change RV2 with two people present. Witness #2 (W2) reported that RP1 had also waited in the past to change RV1_x001A_s incontinence garments until home health arrived. Licensee failed to provide peri-care in a timely manner, failed to follow RV1_x001A_s and RV2_x001A_s care plans and failed to treat RV1 and RV2 with dignity and respect. Licensee_x001A_s failure is a violation of residents_x001A_ rights, is considered neglect and constitutes abuse.",3,600,,,Neglect +CO16100,510143,AFH,3/9/2016,,4,,Substantiated,Substantiated,Neglect +CO11055,510146,AFH,4/6/2011,,2,250,,, +CO11145,510146,AFH,10/7/2011,"The licensor conducted a monitoring visit of the licensee_x001A_s Adult Foster Home on August 11, 2011. During the visit the licensor discovered that the licensee had not documented the quarterly fire drills. The last documented fire drill was on February 5, 2011. The licensee_x001A_s failure to conduct quarterly fire drills is a violation or Oregon Administrative Rules. NOTE: email sent to AR to begin the aging process on 1/10/13",3,150,,, +CO11026A,510283,AFH,12/9/2010,Failure to review and update resident care plans every six months.,3,350,,, +CO11026B,510283,AFH,12/9/2010,Failure to have verification from BCU prior to allowing cg to work in home.,0,0,,, +KF103815A,510391,AFH,3/22/2010,"On or about March 22, 2010, it was reported that the licensee (RP) had failed to follow Resident #1's (RV1) physician's orders. RV1's physician's order dated December 3, 2008 indicated that his/her blood pressure was to be taken daily. A physician's order dated March 19, 2010 reflects that RV1's blood pressure should be checked once per week. There was no discontinue order for the December 3, 2008 order. Documentary observations indicate that the licensee did not check RV1's blood pressure as frequently as ordered. Facility failed to follow physician's orders. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF103815B,510391,AFH,3/22/2010,"On or about March 22, 2010, it was reported that Reported Perpetrator #1 (RP1) failed to provide an environment safe from inappropriate language. RP1 made statements to Resident #1 (RV1) that were derogatory or uncaring. RP1 also made statements that caused RV1 to be feel fearful or insecure that the adult foster home would be closed by the ""State"" or due to RP1's personal finances. RV1 isolated him/herself in RV's room to avoid being yelled at. The facility failed to provide a safe environment for RV1. The failure is a violation of residents rights and constitues verbal abuse.",2,0,,,Verbal/Mental abuse +CO13152,510436,AFH,12/2/2013,"On December 2, 2013, the licensor conducted an annual renewal inspection at the licensee_x001A_s adult foster home (AFH). During the inspection the licensor tested the required smoke alarm in the licensee_x001A_s bedroom. The smoke alarm did not make any sound and upon further inspection it was discovered the batteries had been removed from the smoke alarm. The licensee failed to maintain all required smoke alarms in functional condition. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +CO11081,510508,AFH,5/22/2011,Licensee force fed resident resulting in bruises to cheeks and jaw and acute aspiration pneumonia requiring hospitalization.,4,0,,,Physical Abuse +GP117061,510508,AFH,5/23/2011,"It was reported that on or about May 23, 2011, Licensee failed to protect Resident #1 (RV1) from physical harm. RV1 had bruising on his/her hands and arms as a result of being pulled by the hands and arms to get RV1 out of his/her chair. Additionally, RV1 had bruising to the chin and jaw as a result of Licensee touching RV1's chin and jaw to get RV1 to release the spoon while being fed. Licensee's failures are a violation of resident rights and constitute physical abuse.",2,0,,,Physical Abuse +CO12094,510508,AFH,9/4/2012,Licensee has failed to maintain a safe medication administration system. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.,2,200,,, +GP120374,510508,AFH,6/27/2012,"It was reported that on or about June 28, 2012, Licensee failed to provide a safe medication administration system for Resident #1. Resident #1 had doctors orders to take medication #1 three times a day. Licensee changed Resident #1's doctor order from scheduled to as needed. Licensee was Unable to locate the doctors order for medication #1 that indicated a change from scheduled to as needed. Resident #1's Medication Administration Record (MAR) indicated that Resident #1 didn't receive medication #1 on a regular basis from June 1, 2012 through June 20, 2012. Licensee's failures are a violation or Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +GP121026A,510508,AFH,9/11/2012,"On or about September 11, 2012, Licensee failed to protect Resident #1 (RV1) from rough treatment. Witness #1 (W1) went to the Adult Foster Home to give RV1 a bath. RV1 asked W1 his/her name repeatedly and W1 responded to RV1 with his/her name each time. RV1 continued to ask for W1's name and Licensee responded by cradling RV1's head with one hand and his/her other hand was on RV1's bed supporting Licensee's own weight, not RV1's weight. Licensee's failure to protect RV1 from rough treatment is a violation of Oregon Administrative Rules and constitutes physical abuse. Wrongdoing on the part of the Licensee was substantiated.",3,0,,,Physical Abuse +GP121026B,510508,AFH,9/11/2012,"On or about September 11, 2012, Licensee failed to provide Resident #1 (RV1) with appropriate skin care. Licensee was mistakenly using body wash as lotion on RV1's face. RV1's face was dry, reddened and was sloughing skin. One week after Witness #4 had pointed out Licensee's mistake of using body wash instead of lotion on RV1, RV1 facial complexion was greatly improved. Licensee's failure to provide appropriate care to RV1 is a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +GP121026C,510508,AFH,9/11/2012,"It was reported that on or about September 11, 2012, that Licensee failed to protect Resident #1 from being inappropriately retrained. Licensee had Resident #1 restrained to his/her bed by having tied Resident #1's sheets to his/her bedrails. Licensee's failures are a violation of Oregon Administrative Rules and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,0,,,Physical Abuse +CO13006,510508,AFH,9/11/2012,"Licensee failed to protect resident rights, failed to protect residents from abuse and failed to provide a safe medication administration system. Licensee's failures are a violation of Oregon Administrative Rules and constitute abuse.",3,0,,, +CO13018,510508,AFH,9/11/2012,"Licensee failed to protect resident rights, failed to protect residents from abuse and failed to provide a safe medication administration system. Licensee's failures are a violation of Oregon Administrative Rules and constitute abuse.",3,0,,,Sexual abuse +GP132578,510508,AFH,3/6/2013,"It was reported that on or about March 6, 2013, Licensee failed to protect Resident #1 from verbal and physical harm. Witness #2 saw Licensee strike Resident #1 and overheard Licensee strike Resident #1 numerous times in January and February of 2013. Licensee's failures are a violation of Oregon Administrative Rules, and is considered physical abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Physical Abuse +BH132599,510533,AFH,3/4/2013,"On or about March 4, 2013, it was alleged that Reported Perpetrator (RP) failed to provide Reported Victim (RV) with appropriate care. On one occasion Witness #1 (W1) saw RV, and RV's incontinance brief was soaked with urine and it appeared that it had been that way for a long period of time. A second time W1 saw RV in the morning and again RV's incontinace brief was soaked with urine. Witness #4 (W4) visits RV daily for several hours, and during that time RV is never checked to see if RV's incontinance garment needs changed. It was determined the licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14108,510533,AFH,5/19/2014,"On May 19, 2014, the licensor conducted a monitoring visit at the licensee's adult foster home (AFH). Upon arrival the licensor identified caregiver (RD) as the only caregiver on duty. It was discovered that RD did not have a cleared criminal background check as a substitute caregiver. The licensee had an approved criminal background check for RD as a family member only. The licensee's conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +MS118195B,510605,AFH,10/11/2011,"It was reported on or about October 11, 2011, that the Licensee failed to protect Resident #1 (RV1) from financial exploitation. Licensee admitted to taking RV1's money and using it for personal use. Wrongdoing on the part of the Licensee was substantiated.",0,0,,,Financial abuse +MS118189A,510605,AFH,10/11/2011,"It was reported that on or about October 11, 2011, Licensee failed to provide the appropriate care to Resident #1 (RV1). Licensee admitted to not providing RV1 with appropriate foot care. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +MS118189B,510605,AFH,10/11/2011,"It was reported that on or about October 11, 2011, Licensee failed to maintain a safe medication administration system. Licensee failed to ensure Resident #1's (RV1) pain medications were written on his/her Medication Administration Record (MAR), and failed to initial RV1's MAR after administering medications. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +GP118352,510615,AFH,6/30/2011,"On or about June 30, 2011, it was reported that the Licensee failed to protect RV1 from financial exploitation. Reported Perpetrator #2 (RP2) admitted to using RV1_x001A_s ATM card to withdraw money from RV1_x001A_s account without RV1_x001A_s knowledge or permission.",3,0,Substantiated,,Financial abuse +ES164618,510661,AFH,2/3/2016,"It was reported that on or about February 3, 2016, that Licensee failed to provide a safe environment for RV1 and RV2. Wrongdoing on the part of Licensee was substantiated.",1,,Substantiated,Substantiated,Verbal/Mental abuse +GP117830,510774,AFH,8/29/2011,"On or about August 29, 2011, it was reported that the Licensee failed to protect Resident #1 (RV1) from inappropriate verbal comments. Licensee called RV1 a substance abuser and a liar while Witness #1 was present. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO16078,510851,AFH,3/17/2016,,1,,,, +HB132496,511082,AFH,2/25/2013,"Resident #1 reported that Reported Perpetrator #2 ""smacked"" him/her in the face. Resident #1 raised his/her hands and when Reported Perpetrator_x001A_s hands made contact, Resident #1_x001A_s right ring finger was pushed back. Resident #1 sustained swelling around his/her knuckle and slight discoloration of the skin. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rule.",2,0,Not Substantiated,Substantiated,Physical Abuse +HB149088C,511082,AFH,10/30/2014,"On or about October 30, 2014, a complaint was received that alleged the facility had failed to protect Resident #2 (RV2) from involuntary seclusion. Reported Perpetrator #2 (RP2) stated that RV2 talked excessively during dinner. During the course of the investigation, RP2 acknowledged that he/she had taken RV2_x001A_s food away and sent him/her to his/her room. Resident #1 (RV1), Witness #2 (W2) and Witness #3 (W3) reported that they had witnessed occasions when RP2 had taken away RV2_x001A_s food and sent him/her to his/her bedroom. The investigation concluded that RP2 had secluded RV2 to his/her bedroom. The actions of RP2 are considered involuntary seclusion and constitute abuse. Responsibility for the abuse of RV2 was apportioned to RP2. It was further determined that the facility had failed to provide a safe environment. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Involuntary Seclusion +HB149088A,511082,AFH,10/30/2014,"On or about October 30, 2014, a complaint was received that alleged the facility had failed to protect Resident #1 (RV1) and Resident #2 (RV2) from inappropriate verbal communication. RV1 reported that Reported Perpetrator #2 (RP2) had told him/her to _x001A_shut up_x001A_, _x001A_I don_x001A_t want to deal with you_x001A_ and I_x001A_m done with you_x001A_. RV1 further reported that he/she felt scared when RP2 made these comments. + + + +RP2 stated that RV2 talked excessively. Witness #2 (W2) and Witness #3 (W3) reported that when RV2 would not stop talking at the dining table, RP2 would take away RV2_x001A_s food and send him/her to his/her bedroom. RV1 also related that he/she had witnessed RP2 telling RV2 in a loud voice to _x001A_Go to your room_x001A_. During the course of the investigation, Witness #4 stated that RP2 told him/her that, _x001A_I will tell them [the residents] if they make me angry, I will make them angry_x001A_. + + + +Responsibility for the substantiated verbal/emotional abuse was apportioned to RP2. It was further determined that the facility had failed to provide a safe environment for RV1 and RV2. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +HB153023,511082,AFH,10/2/2015,,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +ES133776A,511211,AFH,7/12/2013,"It was reported that on or about July 12, 2013, Licensee failed to protect resident from bullying. Resident #1 (RV1) made aggressive and abusive statements to Resident #2 (RV2), Resident #4 (RV4) and Resident #5 (RV5). There was no indication of a care plan in place to prevent RV1 from being verbally aggressive with the other resident's. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,,,,Verbal/Mental abuse +ES118408,511283,AFH,11/7/2011,"On or about November 6, 2011, Resident #1 was in the kitchen making coffee. Reported Perpetrator #1 (RP1) and Resident #1 (RV1) both stated RP1 placed RP1's hand on RV1 to direct him/her out of the kitchen. RV1 sustained no injury. Facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rule.",2,0,,, +ES149262,511286,AFH,11/15/2014,"On or about November 17, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim (RV). RV is not prescribed an opiate medication. Witness #3 (W3) has a presription for an opiate medication. On or about 11/15/14 RV was admitted to the hospital due to abnormal behavior. RV was experiencing dizziness and errors on the blood pressure machine. Hospital records including the lab results indicate RV tested positive for opiate medication and was ""likely hospitalized as a result of opiate medication interacting with several other medication and cuasing conditions which required hospitalization."" The licensee failed to provide a safe medication administration system for RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +MV129438A,511432,AFH,2/3/2012,"On or about February 3, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV moved out of RP1's facility on 2/3/12. RV arrived at the new facility with dirty fingernails, and hair and peri area had dried feces. According to RV's care plan, RV was to be bathed three times per week. Staff was to wash RV's hair, back and lower area. RV's care plan states that RV was incontinent with urine and semi incontinent with bowels, and RV would at times urinate and have a bowel in his/her depends. The licensee failed to provide appropriate care to RV. The failure is a violation resident rights, are considered neglect of care, and constitutes abuse.",2,0,,,Neglect +MV129438B,511432,AFH,2/3/2012,"On or about January 3, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to keep RV1's medication administration record (MAR) current and accurate. RP2 admitted to falsely filling in a MAR for the month of January for RV1 for medication #1. RP2 filled in the MAR as having administered medication #1 when RP2 knew that he/she had not administered that medication for the month of January. The licensee failed to keep RV1's MAR current and accurate. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AL120334,511459,AFH,6/12/2012,"On or about June 12, 2012, Resident #1 (RV1) searched for an apartment with the intent to move from the licensee_x001A_s Adult Foster Home (AFH) because of the _x001A_verbal abuse_x001A_ by Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2). RV1 expressed to Witness #6 (W6) that RV1 was going to move out of the AFH. RV1 asked W6 not tell RP1 because RV1 was fearful that RP1 would become angry. W6 told RP1 that RV1 was planning on moving from the AFH the next day. After RP1 found out that RV1 was planning on moving, RP1 went _x001A_ballistic_x001A_ and yelled and screamed at RV1 and called RV1 _x001A_a backstabbing bitch_x001A_. On June 14, 2012, RV1 began to move his/her belongings from the AFH. During the move, RP1 approached RV1 and referred to RV1 as _x001A_A pain in the ass and move out_x001A_. + + + + + +RP1 and (RP2) intimidate and make RV1, Reported Victim #2 (RV2), Reported Victim #3 (RV3) and Reported Victim #4 (RV4) fearful by yelling and making derogatory remarks toward RV_x001A_s. RP1 and RP2 accuse the RV_x001A_s of _x001A_going behind his/her back and talking about him/her_x001A_. As a result RP1 and RP2 restrict RV_x001A_s from communicating freely amongst each other. RP1 admitted that he/she _x001A_did lose my temper_x001A_ on June 12, 2012. RP1 also stated that he/she was upset because he/she wanted RV1 to move out of the facility. RP1 admitted that he/she told RV1 that he/she was a _x001A_backstabber and later, I called RV1 a bitch_x001A_. The licensee failed to protect RV1, RV2, RV3, and RV4 from verbal abuse. The failure is a violation of Oregon Administrative Rule and constitutes abuse. RV1, RV2, RV3, and RV4 requested to move from the AFH.",3,400,,,Verbal/Mental abuse +AL120354,511459,AFH,6/13/2012," + +On or about June 13, 2012, it was reported that 120 narcotic pain medication tablets were missing from Resident #1 (RV1) medication cart. It was verified that RV1 was missing three narcotic pain medication cards. Each card contained thirty narcotic pain tablets totaling 90 missing narcotic pain tablets. + + + +It was discovered that the pharmacy delivered 150 narcotic pain tablets monthly from January 2012 through May 2012 totaling 750 narcotic pain tablets. RV1_x001A_s medication administration record indicates 348 narcotic pain medication tablets were administered to RV1 between January 2012 and May 2012. It was determined that 402 narcotic pain medication tablets were missing from January 2012 through May 2012. Licensee failed to protect RV1 from financial exploitation. The licensee_x001A_s failure is violation of Oregon Administrative Rule and constitutes abuse.",3,400,,,Financial abuse +AL152195,511459,AFH,12/5/2014,"The Department received a complaint on 12/29/2014 that the facility failed to maintain current or accurate medication records. A review of RV1's medication indicated one less dosage than what should have been on hand for RV1's Tramadol prescription, and there was no MAR for RV1's medication. A review of RV2's prescription indicated two less dosages than what should have been on hand for RV2's Methadone prescription. MARS for RV1, RV2 and RV3 were not clear or easy to read.",2,,,, +AL164655,511459,AFH,2/15/2016,"RV pressed her call light/monitor at 4:30a.m. for assistance to go to the restroom. Facility staff did not respond until 7:00a.m. This appears to have been an isolated incident. Facility staff have now been instructed tokeep the monitor next to them when they may be asleep, and turn the volume all the way up.",2,,,, +BH116361A,511478,AFH,2/11/2011,"On or about February 11, 2011 RV1 was confined to his/her room when RP wheeled RV1 to his/her room and closed the door. RV1 was unable to freely come and go from his/he room during the non visiting hours of noon-3pm. RV2 and RV3 were confined to their rooms when they were fed in their rooms and unable to join the other residents at the table during meal times.",2,0,,, +MV134003,511482,AFH,8/2/2013,"Resident #1, Resident #2, Resident #3 and Resident #4 require assistance with medication management. On July 27, 2013 and July 29, 2013, Resident #1's blood sugars were not tested. Resident #2's Medication Administration Record (MAR) for July 2013 indicates that Resident #2's blood pressure was not taken three times per week, as ordered. Resident #3 has an order for Medication #1 to be given three times per day. No doses of Medication #1 were administered on July 26, 2013, July 27, 2013 and July 28, 2013. Medication #2 for Resident #3 was not dispensed on July 23, 2013. Resident #4's medication cream is to be applied twice daily. The July 2013 MAR for Resident #4 reflects that Resident #4 was not administered the cream as ordered on more than one occasion. Facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",2,,,, +MV150273,511482,AFH,2/12/2015,"On or about February 12, 2015, Reported Victim #1 (RV1) communicated to Witness #1 (W1) that the previous evening, Reported Victim #2 (RV2) entered RV1_x001A_s bedroom and rubbed RV1_x001A_s legs, vaginal area and breasts. RV1 reported that he/she told RV2 to _x001A_stop, get out._x001A_ RV1 stated that he/she did not use the call button for help during the incident because he/she was _x001A_scared._x001A_ RV1 reported that RV2 also rubbed RV1_x001A_s stitches during the same incident. RV2 stated that he/she only touched RV1_x001A_s knee and helped RV1 with his/her shoes. Reported Perpetrator (RP) believes RV2 did touch RV1 but didn_x001A_t believe it was sexual or malicious. RP acknowledged that RV2 is curious, has boundary issues and no impulse control. W1 and RP acknowledged that RV2 has a _x001A_fixation_x001A_ with medical procedures. After the incident was reported, RP was notified and law enforcement was contacted. Care plan for RV2 dated 10/17/2014 under behavioral interventions notes that RV2 has boundary issues and is intrusive to others. RV2_x001A_s behavioral care plan dated 11/16/2014 notes the following: RV2 talks or acts inappropriate towards staff or peers/ dresses very provocative. RV2 suffers from mental illness and behaves very sexually or dresses inappropriate often. Staff to remind RV2 no touching allowed to others. RV2 is very affectionate. RV2 mostly does this as soon as a caregiver steps around the corner or is busy, sometimes it_x001A_s seen behavior or heard h/h saying. Target Behavior: Remind RV2 there is no touching allowed with others. If RV2 talks about sex or drugs, speak with h/h in private and remind h/h that speaking like that bothers others. The licensee failed to appropriately care plan for RV2 resulting in inappropriate sexual contact to RV1.",3,400,,,Neglect +CO11062,511507,AFH,1/24/2011,"Failed to pay mortgage, home now in foreclosure",3,0,,, +CO11078,511507,AFH,6/16/2011,Failure to obtain a license to operate an adult foster home,3,250,,, +NB120320,511637,AFH,6/20/2012,"On multiple occasions, the Licensee administered a medication to Resident #1 by placing it in his/her juice or soup. Resident #1 was not aware they were being given the medication. Facility failed to inform Resident #1 of the medication regimen and allow him/her an opportunity to consent or refuse treatment. The failure is a violation of Oregon Administrative Rule.",2,0,,, +CO12114,511641,AFH,11/28/2011,"On October 9, 2012, the licensor conducted a renewal inspection of the licensee_x001A_s Adult Foster Home (AFH). During the inspection the licensor found that the batteries were removed from the smoke alarms in Resident #2 and Resident #3_x001A_s bedroom. The licensor also discovered that the batteries were removed from the smoke alarm in the licensee_x001A_s bedroom and the smoke alarm in the hallway. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,1000,,, +MV134042,511802,AFH,8/6/2013,"It was reported that on or about August 6, 2013, Licensee failed to provide proper care to Resident #1. Licensee acknowledged the use of a gait belt to restrain Resident #1 in his/her wheelchair. Licensee did not have physicians order for the use of a restraint on Resident #1. Licensee failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Restraints +HB154030,511807,AFH,12/20/2015,"RV experienced falls on 12/03, 12/11 and 12/16/2015 and became progressively confused. RV was evaluated and monitored by facility staff after every fall and RV's family was notified. RV was taken to the hospital after the fall on 12/03/15 but not after the subsequent falls, based upon RV's family's wishes. RV was becoming increasingly confused. RV was hospitalized on 12/20/2015 with low sodium, multiple acute rib and lumbar fractures and much pain. RV was placed in the Intensive Care Unit where blood tests uncovered a blood infection.",3,400,Substantiated,Substantiated,Neglect +BH116644,511874,AFH,11/27/2010,"An allegation was made that Reported Perpetrator #2 (RP2) used Resident #1's (RV1) cell phone which caused RV1 to incur between $200 and $300 in phone charges. RP2 was interviewed on March 29, 2011 and stated that she/he used RV1's cell phone while RV1 was away from the adult foster home attending dialysis treatments. RP2 indicated that she/he did not realize that there would be charges associated with the use of the cell phone. RP2 stated that she/he is repaying the cell phone charges totaling $300. RV1 and her/his family were unaware that RP2 had used the cell phone until the extra charges were discovered on RV1's phone bill.",2,0,Not Substantiated,Substantiated,Financial abuse +BH116350,511874,AFH,2/1/2011,"Resident #1 (RV1) was a resident of Reported Perpetrator #1's (RP1) adult foster home. At the time RV1 was admitted, he/she was able to transfer himself/herself and did not require care at night. A few days following admission to the home RV1's condition declined rapidly. RV1 required assistance with ambulation and required assistance at night. RV1 was prescribed a narcotic medication for pain and shortness of breath. The medication was to be administered as needed, when RV1 was short of breath. Witness #2 (W2) and Witness #3 (W3) both noted RV1 to be short of breath when arriving for their respective visits.",2,0,,, +BH116667,511874,AFH,3/2/2011,"A concern was reported that the facility failed to provide a safe environment for Resident #1 (RV1). RV1's medical diagnosis includes memory loss and confusion. According to Reported Perpetrator #1 (RP1), Witness #1 (W1), Witness #2 (W2) and Witness #3 (W3), RV1 has attempted to leave the facility on more than one occasion. On March 2, 2011 at approximately 11:00 pm RV1 left the facility. Facility staff were able to persuade RV1 to return to the building. RP1 failed to revise and update RV1's care plan to include interventions to help prevent RV1 from eloping from the facility.",2,0,,, +BH117672,511874,AFH,9/5/2010,"Resident #1 (RV1) was admitted to the adult foster home on July 29, 2010. RV1's assessment paperwork was reviewed on September 5, 2010 and found to be inadequate and incomplete. RV1 experienced a fall on September 4, 2010 but was not found until 8:00 am on September 5, 2010. It was determined that RV1 was left on the floor for approximately 10 hours and was found to have vomit and feces on him/her. RV1 did not suffer any broken bones but did experience some skin irritation from lying in his/her bodily fluids.",2,0,,, +CO15221,511889,AFH,10/26/2015,For failure to have current approved background checks.,3,250,,, +NB150470A,511906,AFH,3/4/2015,"On or about March 5, 2015, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide appropriate care to Reported Victim (RV). RV received a pessary in May 2014. RV had no issues with the pessary for approximately nine months. RP2 noted some spotting of blood in December 2014. During a routine visit on December 23, 2014, RV's physician did not note any bleeding when the pessary was removed. On or about January 27, 2015, RV complained of constipation. RP2 administered three enemas to RV. RP2 did not have physician orders as required to administer the medication. RP2 did not consult with a medical professional before administering the enemas. RV reported the incident as a fecal impaction removal and stated that it was very painful. During the incident RV requested that RP2 contact a medical professional but RP2 refused. RP2 denied peforming a fecal impaction but acknowledged administering three enemas. From January 2015 through March 2015 RV experienced substantial vaginal bleeding. RV did not receive medical care for the bleeding until March 13, 2015, when it was discovered that RV had deep abrasions on his/her vaginal wall. Witness #3 (W3) stated the abrasions on the vaginal wall could have been caused by constipation, but is more likely due to the use enemas or a fecal impaction removal. W3 noted that long term vaginal bleeding with the pessary could have resulted in permanent damage.",3,,Not Substantiated,Substantiated,Neglect +NB150470B,511906,AFH,3/4/2015,"On or about March 5, 2015, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim (RV) from rough treatment. RV reported to multiple witnesses that on one occasion RP2 forcibly turned RV's neck causing RV pain. On a separate occasion RP2 assisted RV in a rough manner by grabbing RV's arm which caused RV pain. On multiple occasions if RP2 didn't like what RV was wearing then RP2 would forcibly remove clothing from RV and force RV to wear clothing RV did not want to wear. RP2 denied that any of the incidents occurred.",2,,Not Substantiated,Substantiated,Physical Abuse +NB150470C,511906,AFH,3/4/2015,"On or about March 5, 2015, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim (RV) from inappropriate verbal comments. RP2 was aware that RV feared being transferred to a nursing facility. On multiple occasions RP2 would tell RV that he/she would have to move to a nursing facility because RV's care needs were too difficult for an adult foster home. As a result, this casued RV emotional distress.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +BH134320,511929,AFH,7/31/2013,"On or about July 31, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim (RV). RP1 had an alarm on the door to alert the caregiver if a resident attempted to exit. On 7/31/2013 Reported Perpetrator #2 (RP2) turned the door alarm off and left the door open to let in fresh air. RV exited the adult foster home and was found approximately forty five minutes later by a neighbor some distance away. RV did not sustain any injury. RV is a known exit seeker. RV's care plan states that RV is to be cued and re-directed when he/she attempts to exit the adult foster home. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL121306,512006,AFH,9/4/2012,"It was reported that on or about September 4, 2012, Licensee failed to protect Resident #1 from financial exploitation. Licensee advised Reported Perpetrator #2 (RP2) previously that he she had to return a care that was given to him/her from a resident of Licensee's Adult Foster Home (AFH). Rather than returning the car to the Resident, RP2 stated that he/she took the car to the junk yard and got $50.00 for it and he/she kept the money. Additionally, RP2 borrowed $5.00 from a resident because he/she needed gas money. On or about August 30, 2012, Resident #1 reported that he/she loaned RP2 $3000.00 in cash and RP2 had not repaid Resident #1 except in soda pop and cookies. Licensee's failures are a violation of Oregon Administrative Rules. RP2 actions are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,Not Substantiated,Substantiated,Financial abuse +ES118590,512116,AFH,10/12/2011,"It was reported that on or about October 12, 2011, Licensee failed to seek timely medical treatment for Resident #1 (RV1). On October 13, 2011, Witness #3 (W3) who is a relative of RV1, fed RV1 solid food. As a result of being fed the solid food RV1 choked on the food and the food had to be dislodged from RV1 throat by Witness #7 (W7). Licensee failed to seek medical attention for RV1 despite him/her despite being medically fragile and choking. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES150263,512116,AFH,2/12/2015,"On or about January 13, 2015, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV's care plan dated 11/11/2014 notes that RV requires assistance with cognition. RV fell on 1/29/2015 and sustained a significant skin tear on his/her right forearm. Discharge worksheet dated 1/29/2015 notes that RV's dressing is to be changed daily, and to leave steri-strips in place. RP stated that he/she changed the dressing every other day and would change the top but not the dressing underneath. Witness #2 (W2) stated that there is no way the bandage was changed two days prior. W2 stated that the dressing had to be cut off with scissors. W2 continued to say that it is likely that the dressing was never changed. Emergency room department notes dated 2/12/2015 notes that the wound appears to be infected and has drainage and the infection in RV's arm is greater than two days. The licensee failed to provide appropriate skin care. The failure is a violation of residents rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +HB146719,512252,AFH,4/11/2014,"It was reported that on or about April 11, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). RV1 had a health status change and successfully eloped from Licensee's Adult Foster Home unsupervised on multiple occasions on April 11, 2014. Law enforcement pickey up RV1 and returned him/her to the AFH on the first occasion. On the second occasion law enforcement transported RV1 to the hospital. Licensee's failures are a violation of Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee and RP2 was substantiated. SENT FOD AND E-MAILED LLA Barroso Eloisa",3,400,Substantiated,Substantiated,Neglect +BO150056B,512452,AFH,1/9/2015,"On or about January 9, 2015, APS received a complaint that the facility failed to provide appropriate care for RV. During the course of the investigation, APS substantiated that RV2 has no written incidents of falling, nor does the care plan address RV2's sliding/falling. RV2 did slide out of his/her chair and to the floor and stayed on the floor without staff assisting to lift RV2 until after finished helping another resident. Once they completed assisting the other resident, staff lifted RV2 off the floor. The family is aware of RV2's sliding and RV2 does slide out of his/her chair often without hurting him/herself. The facility failed to provide services and the failure is a violation of Oregon Administrative Rule.",2,,,, +BH105968C,512474,AFH,9/15/2010,"On or about July, 2010 RV's medications were changed by hospice staff. RP did not realize the medications had been changed, and failed to double check orders when the MARS from pharmacy did not match the medications RV should be receiving. RV did not receive medications as ordered.",1,0,,, +CO14139,512518,AFH,7/7/2014,"A renewal visit was conducted on July 6, 2014, at the licensee's adult foster home (AFH). Upon arrival the licensee and caregiver TS were present. It was discovered that TS criminal background check had expired on 10/22/2013. The licensee's plan of operation dated 6/19/2014 notes that TS works unsupervised Monday through Friday 9am-5pm. TS and the licensee acknowledged that TS had been working in the AFH since October 2013. A background check for TS was submitted on 6/20/2014. The licensee's conduct constituted a failure to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,250,,, +KF132722,512551,AFH,3/22/2013,"Witness #2 and Witness #6 each reported that they had overheard Resident #1 asking Reported Perpetrator #2 at approximately 10:30am if Resident #1 could come out of Resident #1's room. By witness account, Reported Perpetrator #2 responded to Resident #1 by stating that Resident #1 had to wait until 11am. Other residents were observed dressed and seated around the home. Licensee failed to protect Resident #1 from being restricted to his/her room. The failure is a violation of resident rights, is considered involuntary seclusion and constitutes abuse.",2,0,,,Involuntary Seclusion +HB129497,512585,AFH,3/14/2012,"On or about March 14, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care and services to Reported Victim (RV). RV is diagnosed with a medical condition that limits his/her ability to move. RP was informed that RV should be transferred out of bed into a wheelchair daily. RV expressed that he/she would like to get out and socialize with other residents. RP declined to use a Hoyer lift that was delivered to RP, and did not transfer RV into wheelchair daily as instructed. As a result, RP determined that RV's care needs were beyond RP's abilities and RV was given a 30 day eviction notice. The licensee failed to provide appropriate service to RV. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +GP116870,512588,AFH,5/2/2011,Licensee charged Resident 1 above the established rate for room and board services.,2,0,,,Financial abuse +MS129949,512641,AFH,4/27/2012,"On or about April 27, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV was scheduled to be moved from the facility on April 27, 2012. During the move RV soiled him/herself. Witness #2 (W2) asked Reported Perpetrator #2 (RP2) to clean RV's incontinence supplies. RP2 would not change RV's incontinence supplies stating that RP1 knows how to change RV, not RP2. RV left the facility in soiled incontinent supplies. The licensee failed to provide appropriate care and services to RV. The failure is a violation of Oregon Administrative Rule.",2,0,,, +CO11046,512649,AFH,4/12/2011,,3,500,,, +CO11098,512676,AFH,7/5/2011,,2,250,,, +MM132629,512709,AFH,3/10/2013,"On or about March 10, 2013, it was alleged that Reported Perpetrator#1 (RP1) failed to protect Reported Victim (RV) from rough treatment. RV was at the adult foster home (AFH) awaiting the arrival of a friend. After a while Reported Perpetrator #2 (RP2) informed RV that RV's friend was not coming and that RV needed to go to bed. RP2 told RV that RP2 was going to put RV in h/her bedroom. RP2 forcefully moved RV around in h/her wheelchair. RV became combative with RP2. RP2 began shaking RV's wheelchair. RV reported that it hurt h/her arms when RP2 did this and that RV was in a lot of pain as a result of the shaking. RP2 acknowledged putting RV in bed against RV's will. It was determined the licensee failed to protect RV from rough treatment. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Physical Abuse +MM146861,512709,AFH,4/16/2014,"On or about April 22, 2014, it was alleged that Reported Perpetrator (RP) failed to properly plan Reported Victim's (RV) care. According to RV's pre-admission care plan, RV was ambulatory with assistance and was to be provided with a commode. RV was also provided with a walker to assist in getting to the commode. RV fell twice within the first two days of being admitted to the adult foster home (AFH). After the second fall, RP removed the commode and put RV into incontinence briefs. RV verbally expressed dissapproval of this decision. RV's bedroom door was left open immediately following RV's falls to assist in monitoring RV. The care plan was not completed within the fourteen day timeframe as required. The licensee failed to properly plan RV's care. The failure is a violation of resident rights and constitutes abuse.",2,,,,Neglect +MV148857,512709,AFH,10/1/2014,"On October 1, 2014 the Department received a complaint that the facility failed to maintain an adequate medication management system. The Department investigated and found the facility's medication records to be very disorganized, and RV's records did not match doctor's orders, and RV was given more pain medication than was prescribed. Provider explained s/he gave the pain medication when RV was in pain (prn) even though there was not PRN order for this medication. Other deficiencies in the medication records included missing information on the MAR. The facility has since closed.",2,,,,Neglect +MS145998,512804,AFH,2/5/2014,"It was reported that on or about February 5, 2014, Licensee failed to provide appropriate care to Resident #1 (R1). Upon review on January 28, 2014, it was discovered that R1's skin was excoriated. On February 1, 2014, it was discovered R1's catheter was draining pinkish moderately cloudy urine, and when clothing was removed to change R1, R1's brief was smeared with feces and R1's skin was bright red and excoriated. Licensee's failures are a violation of Oregon Administrative Rules (OARs), is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +MS151566B,512804,AFH,6/12/2015,"On or about June 12, 2015, APS received a complaint that the facility failed to protect RVs from inappropriate verbal comments. During the course of the investigation, APS determined the following occurred: RV2 wanted the music changed to classical and RP2 changed the station to rap b/c RP2 thought it would be funny. RP2 left a sticky note on the table to cue RV1 after dinner, which made RV1 feel like RV1 was in trouble. RP2 referred to RV1 as a ""fat ass"". RV2 heard RP2 tell a resident to ""get up and go to your room"" and was shouting at the resident. RP2 was very stern and rude and had a harsh demeanor towards residents. RP2 meant to degrade RV1 and RP2 was mean to RV1. RP2 thought residents were manipulative and being difficult in order to frustrate RP2. RP1 knew that RP2 had anger but was not aware it was affecting residents. The facility failed to ensure that caregivers treat adults with respect and dignity. This failure is a violation of resident rights and is a violation of Oregon Administrative Rules.",2,,,, +KF151014,512900,AFH,4/14/2015,"On or about April 22, 2015, the Department received a complaint which alleged Licensee (RP) had failed to maintain an adequate medication administration system. + + + +Licensee was responsible for providing appropriate care and services for Resident #1 (RV). RV also received medical oversight from an external entity whose staff coordinated RV_x001A_s end-of-life care. During the course of the investigation, the Adult Protective Services Specialist (APSS) discovered that on more than one occasion RV_x001A_s outside support specialists were not able to obtain and/or monitor RV_x001A_s medication supplies as RP_x001A_s caregivers were not able to access the locked medication cabinet when Licensee was out of the facility. + + + +APSS also discovered that Licensee gave _x001A_extra doses_x001A_ of a sleep supplement to RV. Licensee did not contact RV_x001A_s medical professional or obtain a written order prior to dispensing the additional doses, nor document them on RV_x001A_s Medication Administration Record (MAR). + + + +Additionally, RV was prescribed a pain medication. Witness #2 reported that RV did not receive his/her pain medication because Licensee had allowed RV_x001A_s supply of pain medication to become exhausted. RP did not attempt to coordinate with RV_x001A_s end-of-life care specialists or contact RV_x001A_s medical professional for clarification regarding the existing orders and/or to receive a written order to discontinue RV_x001A_s pain medication. + + + +Licensee failed to ensure that all scheduled and as needed (PRN) medications were available in the AFH at all times, failed to implement orders as written, failed to obtain a written order, failed to maintain accurate medication administration records, and failed to provide a safe environment for RV. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse. + + + +Furthermore, RP acknowledged that she had given RV _x001A_extra_x001A_ doses of an antipsychotic medication when RV was _x001A_acting out_x001A_. RP did not contact RV_x001A_s medical professional, nor obtain a written order prior to administering additional doses of a psychoactive medication. RP acknowledged that she did not accurately document the amount of antipsychotic medication given to RV on RV_x001A_s medication administration record. + +Licensee failed to contact a licensed medical professional to conduct an assessment, failed to use less restrictive alternative measures and failed to have a written order prior to administering additional doses of psychoactive medication to keep RV from _x001A_acting out_x001A_. Licensee_x001A_s failure is a violation of residents_x001A_ rights, is considered wrongful use of a chemical restraint and constitutes abuse.",3,900,Substantiated,Substantiated,Neglect +CO15261,512900,AFH,12/23/2015,"Medication Administation, Expired food, Fire drills outdated",3,800,,, +MF120044A,512984,AFH,5/15/2012,"On or about May 15, 2012, it was reported that Licensee failed to provide appropriate care to Resident #1 (RV1) and Resident #2 (RV2). RV1 and RV2 were not able to ambulate and completely care dependent. Licensee had Witness #2 (W2) put RV1 and RV2 to bed at 6:30 PM despite RV1 verbalizing he/she does not want to go to bed at 6:30 PM. Licensee would tell RV1 to stay in his/her room and close the door because it was bedtime. RV1 and RV2 would remain in their room until W2 would arrive to work at 8:00 AM the next morning. On the morning of May 13, 2012, at 8:00 AM when W2 arrived to work Licensee greeted W2 at the front door and said that RV1 was waiting for W2. When W2 entered RV1's room he/she found RV1 lying on the floor soaked in feces and urine. Additionally, Licensee stated that he she does not provide night care and does not provide 24 hour care. Licensee's failures are a violation of Oregon Administrative Rules, are considered neglect and constitute abuse. Wrongdoing on the part of Licensee was substantiated.",2,0,,,Neglect +MS121493,512984,AFH,9/14/2012,"It was reported that on or about September 14, 2012, Licensee failed to provide appropriate care for Resident #1. Resident #1 went to the hospital and was disharged with two medications to begin administion on September 15, 2012. Licensee failed to have the pharmacy fill Resident #1's pain medication and Resident #1 went without his/her pain medication until September 17, 2012. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the Licensee was substantiated.",2,0,,, +MF120044,512984,AFH,5/15/2012,"On or about May 15, 2012, It was reported that Licensee failed to provide adequate care to Resident #1 (RV1) and Resident #2 (RV2). RV1 and RV2 wwere not able to ambulate and were completely care dependent. Licensee had Witness #2 (W2) put RV1 and RV2 to bed at 6:30 PM despite RV1 verbalizing he/she did not want to go to bed at 6:30 PM. Licensee would tell RV1 to stay in his/her room and close the door brcause it was bedtime. RV1 and RV2 would remain in their beds until W2 would arricve to work at 8:00 AM the next morning. On the morning od May 13, 2012, at 8:00 AM when W2 arrived to work Licensee greated W2 at the front door and said RV1 was waiting for W2. When W2 entered RV1's room he/she found RV1 lying on the floor soaked in feces and urine. Additionally, Licensee stated that he/she does not provide night care and does not provide 24 hour care. Licensee's failures are a violation of Oregon Administrative Rules, are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +MS105576,513039,AFH,10/28/2010,"On or about June 2010 through October 2010, Licensee failed to provide appropriate care to Resident 1. Licensee sought RN consultation due to Resident 1's increased falls but failed to install the alarm ordered by the RN on August 13, 2010 and delivered to the Licensee on August 17, 2010. Resident 1 fell 18 times from June 12, 2010 through October 28, 2010 suffering multiple bruises.",2,0,,,Neglect +MS134347B,513039,AFH,9/9/2013,"On or about September 10, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #3 (RV3) from inappropriate verbal comments. Witness #2 (W2), Witness #3 (W3) and Witness #4 (W4) observed a verbal altercation between Reported Perpetrator #2 (RP2) and RV3. RP2 was observed as being unprofessional and not respectful toward RV3. RP2 was observed speaking in a ""demeaning fasion"" toward RV3. RP2 was observed being ""verbally aggressive, demeaning and inappropriate"" toward RV3. RP2 was observed telling RV3 to ""be quiet, be quiet, be quiet"" and to ""go to your room, go to your room, go to your room."" The licensee failed to protect RV3 from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES105657A,513056,AFH,11/4/2010,"On or about November 4, 2011 RV wandered away from the facility and fell resulting in injury. Licensee was advised to install door alarms. Alarms were installed, but were not always activated and RV wandered away from the facility at other times.",2,0,,, +ES105657B,513056,AFH,11/4/2010,AV's physician infomed Licensee to discontine a medication. Licensee continued to administer this medication until an RN discovered that the medication had been discontinued.,2,0,,, +ES129646,513056,AFH,3/23/2012,"It was reported that on or about March 23, 2012, Licensee failed to maintain a adequate medication administration system for Resident #1 (RV1). RV1 did not receive his/her scheduled medications as perscribed. Licensee routinely went 60, 90 and 120 days between picking up 30 day supplies of RV1's medications. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO13106,513089,AFH,8/13/2013,Unqualified caregiver (expired backgropund check),2,700,,, +CO14152,513089,AFH,5/14/2014,"On May 14, 2014, the licensor made an unannounced visit to the licensee_x001A_s adult foster home (AFH) in response to a complaint. The licensee was licensed to operate with a capacity of five residents and two room and board individuals (R1 and R2). Upon inspection of the resident records it was discovered a screening and assessment was completed for R1 on 7/1/2012. The screening and assessment for R1 noted that R1 required assistance in bathing/personal hygiene, toileting, cognition/behavior management, emergency exiting and night needs. A care plan was created for R1 on 7/1/2012 and details R1 care needs. Narratives for R1 note the administration of medication to R1 by AFH staff on multiple occasions. A medication administration record (MAR) was maintained and initialed as medications being administered to R1 by AFH staff. + + + +A screening and assessment was completed for R2 and notes that R2 requires assistance in all of the activities of daily living which include eating/nutrition, bathing, dressing/grooming, and mobility/transfer. A MAR was maintained and initialed as medications being administered to R2 by AFH staff. Narratives for R1 note the administration of medication to R2 by AFH staff on multiple occasions. A care plan was created for R2 and details R2_x001A_s care needs. R1 and R2 required care and were not considered room and board. The number of residents exceeded the licensed capacity. FOD MAILED AND COPY E-MAILED TO LLA",3,200,,, +MS148108,513089,AFH,8/12/2014,"It was reported that on or about August 13, 2014, Licensee failed to protect Resident #1 (RV1) from a loss of medications. Licensee failed to provide a system that prevents a theft or misuse of medications resulting in a loss of RV1's medications. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Licensee's failures are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Financial abuse +JD135164,513097,AFH,3/14/2013,"On or about March 15, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV's care plan dated 3/11-3/15/13 notes that RV requires assistance to use the commode. RV's physician order dated 10/2011 notes that RV has a script for physical restraint ""1/2 rail"" use. The physician order continues to note that RV was to be moved every two hours. RP acknowledged that he/she does not assist RV to the commode and does not reposition RV. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD117405,513145,AFH,5/29/2011,"On or about May 31, 2011, Licensee wrongfully used a physical restraint. Resident 1 was physically tied into their wheelchair with a gait belt. Licensee did not have an assessment, did not attempt less restrictive measures and did not have a physician order for this restraint.",2,300,,,Restraints +CO13097,513169,AFH,8/9/2013,,4,0,,, +GP103949,513284,AFH,4/7/2010,"It was reported that on or about April 7, 2010, Licensee failed to follow physician's orders for Resident #1's (R1) medications. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +GP153701,513284,AFH,11/24/2015,"It was reported that on or about November 24, 2015, Licensee failed to provide appropriate care to Resident #1 resulting in Resident #1 sustaining multiple falls. Wrongdoing on the part of the Licensee was substantiated.",1,,Substantiated,Substantiated,Neglect +HB146092,513337,AFH,2/18/2014,"During a facility investigation conducted on or about February 18, 2014, the investigator discovered the Licensee had failed to provide the appropriate care and services to Resident Victim #1 (RV1). Licensee failed to ensure proper staffing to meet RV1_x001A_s care needs. Licensee, Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) failed to follow RV1_x001A_s care plan. Licensee, RP2 and RP3 failed to ensure RV1 received appropriate hygiene care, failed to ensure RV1_x001A_s incontinent garments were changed timely and failed to take the necessary steps to prevent RV1_x001A_s skin break down resulting in RV1 having sustained a pressure sore on his/her Coccyx. FOD and notice sent to LLA",3,400,Substantiated,Substantiated,Neglect +HB148372,513337,AFH,9/3/2014,"Resident #1 (RV) was at risk for skin issues due to incontinence and mobility limitations. Resident #1_x001A_s care plan dated March 31, 2014 indicated that RV must be monitored for skin alterations and that any occurrence of skin issues must be reported to the RN immediately. + + + +Reported Perpetrator #2 (RP2) acknowledged that he/she first noticed a rash on RV on September 1, 2014 and applied cream. A progress note written by RP2 on September 2, 2014 indicated that, _x001A_There is already a rash [on RV] so the caregiver cleaned it with wound cleaner and put on some cream._x001A_ The progress note for September 3, 2014 mentioned, _x001A_[RV_x001A_s] rash is worse and there is some yeast. The caregiver called home health and they said a nurse will come and visit [RV]._x001A_ The RN_x001A_s narrative entry dated September 3, 2014 described the skin as, _x001A_Has flaming red yeast appearing rash to buttocks, peri area and spots on left hip. Will treat with antifungal cream_x001A_. Witness #3 (W3) reported that RV also required an oral anti-fungal medication. Home Health Clinical Note from September 8, 2014 indicated that RV_x001A_s yeast rash had great improved. The Clinical Note dated September 17, 2014 stated that the yeast rash had cleared. + + + +RP2 failed to follow RV_x001A_s care plan and failed to notify RV_x001A_s medical professional when RV experienced a change in condition. Licensee failed to provide appropriate care and services to RV, failed to exercise reasonable precautions against any condition that threatened the health, safety and welfare of RV and failed to provide a safe and secure environment for RV. Licensee_x001A_s failure is a violation of residents_x001A_ rights, is considered neglect and constitutes abuse.",3,450,Substantiated,Substantiated,Neglect +CO16106,513337,AFH,4/14/2016,SUSPENSION OF THIS HOME BASED IN PART ON ALLEGATION(S) OF ABUSE AT LICENSEE'S BARLOW ROAD HOME. CONDITIONS WERE PLACED ON BOTH HOMES IN ORDER TO ALLOW DEPT. STAFF TO IDENTIFY NEW PLACEMENTS FOR ALL RESIDENTS BEFORE SUSPENSION(S) WERE SERVED.,4,,,,Neglect +CO15246,513381,AFH,12/4/2015,uqualified Sub Caregiver expired criminal background clearance.,3,250,,, +CO14179,513398,AFH,8/25/2014,Provider and caregiver had expired criminal histoy checks. FOP,2,500,,, +CO15204,513398,AFH,9/28/2015,Civil penalty for licensee's expired background added to #CO15205.,2,,,, +CO15205,513398,AFH,9/28/2015,Pattern of substantial non-compliance: Background checks; med system; smoke/CO testing; and resident records,3,900,,, +ES164268B,513460,AFH,1/12/2016,,2,,Substantiated,Substantiated,Neglect +CO14190,513632,AFH,8/22/2014,"Licensee has repeated instances of unlocked medications, missing medications, missing orders, medication orders not matching current MARs, careplans without information or not updated, not understanding medications, etc.",3,0,,, +CO14206,513632,AFH,8/22/2014,"During a monitoring visit, the local licensing authority (LLA) found that provider had not charted administered medications immediately after administration, as required by OAR. As the LLA was reviewing Resident 1's MAR, the LLA observed the provider take MAR records for resident 2, 3, and 4 and begin to initial on dates/ times for previously administered medications but not indicating on the MAR that provider was charting after the fact. This is considered falsification of records b/c provider attempted to alter records to look as if provider complied with OAR when she did not. FOD and e-mail sent to LLA 12/5/14",2,600,,, +MV120398,513722,AFH,6/25/2012,"On or about June 25, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV exited the home on the night of June 25, 2012. RV was found by RP's neighbors around 4:30am who then contacted law enforcement. RV was found to have fallen and sustained an injury to RV's forehead. RV was then transported to the emergency room for evaluation. Law enforcement attempted to wake up the care giver on duty. It took law enforcement 20 minutes to wake up the care giver. The care giver on duty did not hear the door alarm and the baby monitor put in place was not functional. Care plan for RV indicates that RV has a history of exit seeking. The licensee failed to provide appropriate care to RV resulting in RV being transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO13052,513871,AFH,3/29/2013,"On March 29, 2013, the licensor conducted a renewal inspection at the licensee_x001A_s Adult Foster Home (AFH). During the inspection the licensor discovered a smoke detector located in the main hallway, and a smoke detector located in a bedroom were not functional. Upon further inspection it was found that the batteries were removed from both of the smoke detectors. The licensee failed to maintain all required smoke detectors. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,500,,, +CO12044,513875,AFH,4/16/2012,"A renewal visit was conducted at the licensee_x001A_s adult foster home (AFH) on April 16, 2012. During the renewal the licensor found that the smoke detector in the licensee_x001A_s bedroom was not functional, and upon further inspection discovered that the battery had been removed from the smoke detector. The licensee failed to provide a safe environment. The licensee_x001A_s failure is a violation of Oregon Administrative Rules. NOTE: email sent to AR to begin the aging process on 1/10/13",3,250,,, +ES117891A,513926,AFH,8/28/2011,"It was reported that on or about August 28, 2011, Resident #1 was admitted to licensee's adult foster home. The investigation concluded that the licensee had to physically restrain Resident #1 on multiple occasions to keep Resident #1 from immediate harm and that licensee did not contact a medical professional for further evaluation of Resident #1. Licensee failure to perform an adequate screening and assessment prior to admitting Resident #1 was substantiated.",2,0,,, +ES147492,513930,AFH,6/14/2014,"On or about June 13, 2014, Resident #1 (RV) was in the final stages of dying. Hospice staff and RV_x001A_s family were with him/her to support and care for RV during his/her final hours. During that time, RV experienced heightened anxiety and pain levels. Witness #3 (W3) stated that RV_x001A_s support professionals and RV_x001A_s family were having a difficult time making RV more comfortable. Witness #2 (W2) reported that it took approximately two to two and a half hours to manage RV_x001A_s anxiety with medication. RV was also sensitive to sound and Witness #4 (W4) reported that RV required a calm environment. Licensee (RP) and RP_x001A_s dog came into RV_x001A_s room later that night. Witness #5 (W5) reported that RP was loud and that W5 observed a change in RV_x001A_s breathing when RP entered his/her room. + + + +RV shared his/her room at Licensee_x001A_s Adult Foster Home (AFH). RV_x001A_s roommate was having a difficult time that evening so staff made a comfortable place on the sofa for him/her to sleep. RP later limited the number of family and care team members who could be with RV in his/her room. RP then insisted that staff return the roommate to his/her bed in the shared room. When RP brought the roommate back into the shared room with RV, who was in the active stages of dying, W3 observed that the roommate appeared scared. W4 believed that the roommate should not have been returned to the shared room as it was upsetting to RV and his/her family. W1, W2 and W3 all voiced their objections to RP. During the course of the investigation, RP acknowledged that she did not think it mattered if RV_x001A_s roommate was in the room while RV died. + + + +Witness #3 reported that RP attempted to bring a potential resident into the room while hospice and RV_x001A_s family were with RV that night. W3 was very concerned with RP_x001A_s behavior which disrupted the calmness of the room and RV_x001A_s right to privacy during the provision of his/her care. + + + +RV expired at about 11pm. Afterwards, Witness #5 (W5) wanted to spend time with RV but because RV_x001A_s roommate was there, W5 felt like he/she had to leave. Additionally, W2 stated that although RV died at approximately 11pm, RV_x001A_s body remained in the room with his/her roommate until approximately 1am. + + + +Based upon these facts the Department finds that Licensee failed to treat RV with respect and dignity; failed to provide a home-like environment; failed to allow RV to associate privately with any person(s) of his/her choice; failed to allow RV privacy during the provision of care; failed to keep RV_x001A_s medical condition and personal information private when a potential customer visited RP_x001A_s AFH; and failed to exercise reasonable precautions to prevent conditions that threatened the health, safety and welfare of RV. + + + +Licensee_x001A_s failures are violations of residents_x001A_ rights, are considered neglect and constitute abuse.",3,750,,,Neglect +ES150262,513930,AFH,11/24/2014,"Licensee failed to contact RV1_x001A_s PCP when RV1 had a fall that resulted in a significant change in his/her physical condition and ability to ambulate; failed to seek timely medical assistance for RV1; and failed to exercise reasonable precautions to prevent conditions that threatened the health, safety and welfare of RV1. Licensee_x001A_s failures are violations of residents_x001A_ rights, is considered neglect and constitute abuse. Wrong doing on the part of the Licensee was substantiated.",2,800,Substantiated,Substantiated,Neglect +ES105964,513932,AFH,12/1/2010,"Reported Victim #1 (RV1) was admitted to the facility on November 15, 2010. RV1 was determined to be alert and oriented without any cognitive deficits. RV1 did testing on himself/herself to determine the appropriate medication amount. Facility staff administered RV1's medication some of the time and RV1 also administered the medication some of the time. The facility failed to have physician orders for RV1's medication nor the delegation to administer them.",2,0,,, +HB105956A,514077,AFH,12/13/2010,"On or about December 13, 2010, Reported Perpetrator #2 (RP2) grabbed Reported Victim #1's (RV1) arms. RV1 sustained pain and injury to his/her left arm.",3,0,Not Substantiated,Substantiated,Physical Abuse +HB105956B,514077,AFH,12/13/2010,Reported Perpetrator #2 (RP2) had sexual contact with Resident #1 (RV1). The facility failed to protect RV1 from inappropriate sexual contact. The failure is a violation of Oregon Administrative Rule.,4,0,Not Substantiated,Substantiated,Sexual abuse +HB105956C,514077,AFH,12/13/2010,"On or about December 13, 2010, Resident #1 reported that Reported Perpetrator #2 (RP2) had asked him/her, _x001A_Can I get lucky?_x001A_ RP2 admitted to local law enforcement that he/she had said this to Resident #1. The facility failed to protect Resident #1 from inappropriate verbal communication. The failure is a violation of Oregon Administrative Rule.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +CO12048,514152,AFH,5/1/2012,"On or about May 9, 2011, it was found that Licensee did not have adequate financial resources to cover the operating expenses of her Adult Foster Home (AFH) for two months as required in the AFH Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",4,0,,, +CO12109,514152,AFH,5/15/2012,Licensee failed to meet the financial requirements necessary to operate her Adult Foster Home (AFH).Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiates.,3,0,,, +CO13014,514152,AFH,2/8/2013,"On or about February 7, 2013, the licensor made an unannounced visit the licensee_x001A_s Adult Foster Home (AFH) in response to a complaint. During the visit it was discovered that on 2/1/2013, an unqualified caregiver (VV) transported Resident #1 alone to h/h doctor_x001A_s appointment. According to Resident #1_x001A_s care plan that was last updated on 1/9/2013, Resident #1 has difficulty understanding and communicating with others due to h/h Alzheimer_x001A_s disease. The care plan also states that Resident #1 is incontinent, and is not oriented to time and place. The care plan continues to say that Resident #1 uses a cane and requires stand by assist when walking. VV does not have a current criminal records check. The last approved criminal records check for VV was on 5/31/2011. The licensee failed to provide a safe environment. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. NOTE: FOD sent on 3/28/2013 and email to AR to begin aging process. UPDATE: Sent to DOR for collections on 10/30/13.",3,250,,, +KF132357,514152,AFH,2/1/2013,"On or about February 1, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). On February 1, 2013, RV was brought to see h/h physician due to RV's catheter leaking for the previous five days. During the visit RV's physician discovered that the catheter had been disconnected. The catheter was found to have a foul odor and it was determined that RV had an infection. It was also discovered that due to the catheter leaking, RV sustained a decubitus ulcer on h/h coccyx. The licensee failed to provide appropriate care to RV. The failure is violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +KF132586,514152,AFH,3/7/2013,"On or about March 7, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). Witness #2 (W2) made a visit to the licensee's adult foster home (AFH). W2 observed RV to be laying in urine and dried feces on RV's left side. Since RV was admitted to RP's AFH RV has developed two wounds including one on RV's left hip. It was determined RV was beyond RP's ability to provide his/her care. RV moved to another facility. The licensee failed to provide appropriate care to RV. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,0,,,Neglect +BH105853,514173,AFH,12/8/2010,"On or about December 9, 2010, a report was received stating that Resident #1 (RV1) had left the facility without supervision and was found on the side of the road on the evening of December 8, 2010. RV1's care plan indicated the caregiver is expected to keep monitoring RV1 during the night, redirect, and reorient. The investigation concluded that the facility failed to follow RV1's care plan.",2,0,,, +HB120412,514230,AFH,4/1/2012,"On or about April 1, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). On 4/1/12 RV was admitted to the facility. RV was on end of life care when he/she moved into the facility. RV developed wounds shortly after arriving at the facility. It was determined through interviews and observations that RP was not providing proper care to RV causing wounds to develop and RV's existing wounds not to heal. As a result RV was moved from the facility. The licensee failed to provide appropriate care to RV. The failures are a violation of resident rights, are considered neglect of care, and constitutes abuse.",3,0,,,Neglect +CO11096,514235,AFH,6/13/2011,AFHCP11-034,3,250,,, +CO14215,514235,AFH,9/24/2014,FOD sent out 12/08/14 and e-mailed provider a copy,2,150,,, +KF148664,514235,AFH,9/23/2014,"On or about September 23, 2014, RV attempted to transfer him/herself out of bed and fell to the floor. Resident #1's (RV) care plan documented that RV required two caregivers to assist him/her with all transfers. Reported Perpetrator #2 (RP2) came into RV's room and attempted to lift RV from the floor by him/herself but was unsuccessful. A visitor to the facility then positioned RV's wheelchair behind RV while RP2 lifted RV up by his/her arms. Facility failed to follow RV's care plan which resulted in RV sustaining dark discoloration to RV's upper arms from being lifted by his/her arms. Facility failed to follow RV's care plan. Facility's failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +CO16063,514235,AFH,3/8/2016,"On March 6, 2016, Licensee acknowledged to the LLA she accepted a room and board occupant into the AFH prior to receiving a approved background check. Violation wrote on 3/14/16 and CP approved on 3/31/16 for $200.00",3,200,,, +BH120880,514239,AFH,8/9/2012,"On August 9, 2012, it was found that Licensee failed to provide safe medication administration to Resident #1. From August 3, 2012, through the morning of August 23, 2012, Resident #1 was administered 50mg of medication #1 twice daily. Resident #1_x001A_s order for medication #1 had been changed by his/her physician on August 3, 2012; Licensee failed to transcribe the new medication order to Resident #1_x001A_s Medication Administration Record (MAR). The order change on August 3, 2012, read Resident #1 was to receive 25mg of medication #1 twice daily. On August 23, 2012, Resident #1 was sent to the hospital with symptoms indicative of being over medicated on Medication #1. Licensee's failure is a violation of Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrong doing on the part of the Licensee was substantiated.",3,200,,,Neglect +CO12125,514239,AFH,11/6/2012,Licensee allowed a known felon to reside in the AFH. This individual then intimated Resident 1 causing emotional distress.,3,0,,,Verbal/Mental abuse +BH121509B,514239,AFH,11/2/2012,"On or about November 2, 2012, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee failed to ensure a qualified caregiver was present at all times. Reported Perpetrator #3 (RP3) had worked for Licensee for six days, did not meet caregiver requirements and did not have a criminal history check. RP3 was alone with RV1 while assisting him/her with cleaning his/her private area. While assisting RV1, RV1 stated to RP3 that the water was to hot and that it hurt him/her. RP3 stated that he/she didn't feel the water was hot and continued. RP3's action are considered neglect and constitute abuse. Licensee's failures are a violation of Oregon Administrative Rules are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",3,0,Substantiated,Substantiated,Neglect +MS134315A,514258,AFH,6/10/2013,"On or about June 9, 2013, Resident #1 (RV) twisted his/her hip while transferring him/herself. RV complained of lower leg pain. Reported Perpetrator (RP) called RV's physician on 6/10/2013 and 6/11/2013 and left a message stating that RV did not have RV's strength like usual. On 6/12/2013 Witness #1 (W1) made a visit to the licensee's adult foster home (AFH) to see RV. RV notified W1 that RV was experiencing increased pain. W1 observed RV crying due to the increased pain he/she was feeling. RP stated RV never complained of hip pain, only leg pain. RP stated RV wants attention and RV acts different in front of different people. W1 also observed RV to have bruising on his/her thigh that was purple in color. RV asked W1 to help RV and that RV just wanted out of there. On 6/12/2013 W1 contacted 911 for an evaluation of RV due to sever uncontrolled pain. RV was found to have fractured his/her hip. The licensee failed to intervene when RV's condition changed resulting in increased pain to RV. The licensee's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,400,,,Neglect +MS134315B,514258,AFH,6/10/2013,"On or about June 10, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RV stated that he/she is always yelled at by RP. RV stated that he/she never wanted to go back to the Adult Foster Home (AFH) and that he/she would rather ""live in jail"". RV stated that RP makes him/her upset. RV expressed to Witness #1 (W1) that RV wanted out of the AFH. The licensee failed to protect RV from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS133794,514258,AFH,7/11/2013,"On or about June 12, 2013, Witness #2 (W2) made a visit to the licensee's adult foster home (AFH). W2 did not observe any skin breakdown on Resident #1 (RV) at the time of the visit. On July 11, 2013, W2 made a follow up visit to the licensee's AFH and observed a stage three skin breakdown on RV's tailbone. W2 also observed a blister and skin breakdown on RV's great toe and on the inside of RV's right foot. RV's condition requires RV have a pressure relief air mattress on his/her bed. The licensee (RP1) was aware that the air mattress was leaking air. The home health clinical notes dated 7/10/2013 note RP1 reported that RV's air mattress had a leak for several weeks. RP1 states that he/she would attempt to patch the holes but the bed continued leaking air because the holes were tiny and hard to find. RP1 continued to say that RP1 would fill the air mattress with air at night, but the mattress would be flat by morning. RP1 stated that he/she requested a new mattress for RV, but the insurance said RP1 just to patch the holes. Witness #3 (W3) stated that the request for RV's new air mattress was generated on 7/08/2013 and there had not been a request prior to 7/08/2013. RV's new alternating pressure relief air mattress was delivered and installed on 7/12/2013. On 7/17/2013 adult protective service worker observed the old deflated air mattress was on RV's bed. + + + +Witness #1 (W1) stated that RP1 has great difficulty in following instruction with regard to RV's wound care. W1 stated that specifically RP1 would remove RV's dressing and not reapply RV's dressings as instructed. RV requires to be turned routinely due to his/her wounds. W1 states that even with RV's new air mattress, RP1 could not understand that RV still needed to be turned routinely. APD long term care community nursing services summary dated 7/11/2013 notes that RP1 reported a golf ball size wound to the base of RV's sine area. The summary also notes that a Registered Nurse (RN) reviewed with RP1 the importance of getting RV off of bottom and in bed on side during the day and changing positions frequently. The licensee failed to provide appropriate care and services to RV resulting in RV's condition worsening. The licensee's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,450,,,Neglect +MS134388,514258,AFH,9/11/2013,"On or about September 11, 2013, at approximately 9:30am Witness #2 (W2) made a visit to the licensee's adult foster home (AFH). Licensee (RP) was not present during the time of the visit. RV requires two persons to transfer him/her. Upon arrival W2 observed RV in a recliner and noticed that RV had made a bowel movement. W1 stated to W2 that RV is the one resident that W1 could not transfer. RV was not able to be changed in the recliner. W2 and W1 transferred RV to his/her bed where W2 changed RV and did a skin evaluation. W2 observed a stage II bed sore on RV's right buttock. W1 stated that RP was aware that W1 was not capable of providing appropriate care to RV. UPDATE: FOP sent on 7/30/14 + + + +At approximately 5:30pm RP had not arrived back to the AFH. W1 and W2 attempted to transfer RV from RV's bed into RV's wheelchair for dinner and during the transfer RV fell. Emergency personnel were contacted to get RV up. RV did not sustain any injury from the fall. RP stated that RV was transferred to the recliner at 7:00am. RP stated that staff was instructed to call RP if they needed assistance with RV. RP continued to say that W1 is able to transfer RV with a hoyer. RP acknowledged that RV required a two person transfer. The licensee failed to provide appropriate staffing, care and services to RV. The licensee's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,500,,,Neglect +MF134982,514258,AFH,11/7/2013,"On or about November 7, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). Shortly after RV was admitted to RP's adult foster home (AFH) RP began to apply a jock itch cream to RV's genitals. RP was aware that RV did not have a physicians order for the itch cream. RV stated it made him/her feel uncomfortable. RV is a diabetic. RP feeds RV foods that are not consistent with RV's diet. RV has a wound on his/her foot. RV receives wound care from RP and a home health agency. RV's wound gets wet/soiled when RV steps in urine on the bathroom floor. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rule.",2,,,, +MF135414,514258,AFH,12/17/2013,"On or about December 18, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RV had multiple bouts of diarrhea. RV stated that RP ""scolded"" RV. RP asked RV ""what happened"" and Whats wrong with you?"" RV stated that he/she doesn't like being yelled at by RP. The licensee failed to assure RV's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MF148552,514258,AFH,9/15/2014,"On or about September 16, 2014, it was alleged that Reported Perpetrator (RP) failed to assure timely medical treatment for Reported Victim (RV). On 9/14/2014, RV experienced increased pain and requested an ambulance. RP did not contact 911. On 9/15/14 RV requested an ambulance. On 9/15/14 RP contacted emergency personell and RV was transported to the hospital. The licensee failed to assure timely medical treatment. The failure is a violation of Oregon Administrative Rules.",2,,,, +DA133517,514298,AFH,6/10/2013,"On or about June 12, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide an environment of dignity and respect. Reported Perpetrator #2 (RP2) was observed telling a resident he/she could not use the restroom stating ""You were just in the bathroom. You go in there and play. You're not going again."" RP2 was also observed yelling at a resident, and refusing to help a resident find a television remote control. The licensee failed to ensure residents were treated with dignity and respect. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +DA134686B,514298,AFH,10/3/2013,"It was reported that on or about October 3, 2013, Licensee failed to follow physician's orders for one of Resident #1's medications. Resident #1 has a physicians order to discontinue a medication on September 12, 2013. Upon reviewing Resident #1's medication administration records it was discovered Resident #1 had been administered the discontinued medication after the medication had been discontinued by his/her physician. Licensee's failures are a violation Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO15071,514298,AFH,3/30/2015,,2,250,,, +AS105779,514346,AFH,12/3/2010,"Reported Perpetrator #2 frequently raises his/her voice to the residents, causig some of them to be apprehensive. RP2 has not threatened any of the residents but may be working too many hours and not getting enough time away from the job.",2,0,,, +AS133005,514346,AFH,4/19/2013,"It was reported that on or about April 19, 2013, Licensee failed to ensure Resident #1's medications he/she keeps in his/her room were adequately secured. Reported Perpetrator #2 (RP2) was giving Resident #1 pre-measured doses of pain medication each night to keep at his/her bedside for night pain as directed by hospice. The pain medication was not locked up while at Resident #1's bedside. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO15159,514346,AFH,8/12/2015,Provider allowed caregivers to work on multiple occasions without approved background check.,3,500,,, +AS153855,514346,AFH,11/25/2015,"On or about December 8, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to assess and care plan for RV's outings. During the course of that investigation, APS substantiated that a behavioral support plan addressed RV's outings. Neither RP1 nor RP2 talked with RV about the plan. Safety precautions were not addressed in the facility care plan. Wrongdoing was substantiated. RP1's failure to assess and care plan for RV's outings, which resulted in injury, is a violation of resident rights, constitutes neglect, and is considered abuse.",3,,Substantiated,Substantiated,Neglect +CO16017,514346,AFH,1/7/2016,"Received revocation of license request, based upon: substantial non-compliance; health, safety, welfare of resident; failure to correct violations within time frame given; etc. (Same issues listed for condition action). Provider gave notice to residents to move, Resident manager left the home; License deemed abandoned.",3,0,,, +CO16022,514346,AFH,2/1/2016,Residents were left alone without qualified caregiver. Resident manager Mike Sangari left residents home alone while he ran to the store for ice-cream. Sangari acknowledged this to the local licensing authority on 12/22/15.,3,300,,, +MV145757,514360,AFH,1/6/2014,"It was reported that on or about January 6, 2014, Reported perpetrator #2 (RP2) removed Resiedent #1's (RV1's) medication from Licensee's Adult Foster Home. Licensee's failures are a violation of Oregon Administrative Rules (OARs). RP2's failures are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee was substantiated",2,,Not Substantiated,Not Substantiated,Financial abuse +MV146255,514360,AFH,1/20/2014,"On or about 1/21/14, APS investigated an allegation that RP1 failed to provide appropriate care and treatment. During the course of the investigation, APS substantiated that RV had left side paralysis and the 8/19/13 care plan stated that a caregiver was to put prescription lotion on RV's hands and feet. In December 2013 and January 2014, RV had a prescription for two medicated ointments. Only was was a self-administered medication. From January 1-22, 2014, the medicated ointment that was not self-administer, was not administered by the facility. RP2 gave medicated ointments to the RV to put on by him/herself and did not clean and medicate the legs as directed. As a result, when RV removed TED hose, skin came off as well. Facility's failure to follow physician orders and failure to follow the care plan resulted in RV's skin injury. Facility's failure is a violation of resident rights, constitutes neglect, and is considered abuse.",2,,,,Neglect +MV149166,514360,AFH,10/31/2014,"It was reported that on or about October 31, 2014, Licensee failed to provide appropriate care and medications to Resident #1 (RV1). RV1 had physician's orders for required testing and medication for a medical diagnosis. Reported Perpetrator #2 (RP2) failed to follow physicians orders resulting in RV1 being hospitalized. Licensee's failures are a violation or Oregon Administrative Rules. RP2's failures are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee has been substantiated and abuse has been apportioned to RP2.",3,,Not Substantiated,Substantiated,Neglect +MV153528,514360,AFH,11/9/2015,"On 10/06/2015, while residing in Licensee_x001A_s AFH, Resident #1 (RV1) had a fall that resulted in a laceration to his/her right knee/chin. RV1 was transported to the hospital for treatment following the fall. On 10/15/2015 a Nurse Practitioner (NP) came to the AFH to look at RV1_x001A_s injury and ordered an ointment. Progress note dated 10/16/15, stated _x001A_Didn_x001A_t receive prescription for [RV1] last night._x001A_ Progress note dated 11/06/15, stated RV1 _x001A_leg is still seeping blood through bandages_x001A_. Progress note dated 11/10/15, stated _x001A_[Resident care manager] sent [RV1] to ER for leg wound, it smells really bad. [RV1] came home from ER with antibiotic for wound care_x001A_. Hospital notes indicated RV1_x001A_s _x001A_wound was black in color in the center and dark ark brown and yellow around the edges. There is some green leakage on the bandage that was removed._x001A_ Licensee failed to seek timely medical attention as RV1_x001A_s wound worsened. Licensee_x001A_s failure is considered neglect and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +HB129016,514379,AFH,1/23/2012,"On or about January 23, 2012, it was reported that the Licensee failed to protect Resident #2 (RV2) from theft. RV2 reported their cell phone missing to the licensee. Reported Perpetrator #2 (RP2) contacted the licensee from RV2_x001A_s missing cell phone.",2,0,,,Financial abuse +HB133582,514379,AFH,6/24/2013,"On or about June 24, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). Witness #1 (W1) provides the depends for RV. On multiple occasions RV was observed to be wet. Up until approximately the end of June 2013 RP was using only 1-2 depends per day for the RV. RP began to use more than two depends at the beginning of July 2013. The RP now changes the RV four times per day or as needed. The RP now checks RV twice during the night. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rule.",2,,,, +AL148117,514388,AFH,2/9/2014,"On or around 2/11/14, APS received an allegation that the facility failed to provide appropriate skin care. During the course of the investigation, APS determined that RV has a cognitive impairment resulting in memory lapses and awareness deficits. RV became incontinent of bladder and bowel and remained sitting in a chair for prolonged periods. Due to RV's medical treatment for terminal illness, RV's physician stated to watch for skin breakdown and report significant worsening of the skin to medical facility. RV had not been bathed because RV refused and did not want to remove RV's undergarment. As a result of RV being immobile, RV developed paintful stage 2-3 decubitus ulcers, as well as an axillary open wound that required treatment. RV arrived at the hospital with ""dirty"" skin and skin that had grown over the fabric of RV's undergarment because RV had worn it so long. The facility failed to follow physician orders regarding skin care treatment. The facility's failure is a violation of resident rights, is considered neglect, and constitutes abuse.",3,400,,,Neglect +MS133085,514467,AFH,4/17/2013,"It was reported that on or about April 17, 2013, Licensee failed to protect Resident #1 (RV1) and Resident #2 (RV2) from loss of his/her medications. Reported Perpetrator #2 (RP2) admitted to wrongfully taking RV1's and RV2s medications. Licensee's failures are a violation of Oregon Administrative Rules. RP2's actions are considered financial exploitation and constitute abuse on the part of RP2. Wrongdoing on the part of Licensee was substantiated.",3,,Not Substantiated,Substantiated,Financial abuse +MS150127,514479,AFH,2/4/2015,"On or about 2/4/15, APS received a complaint that the facility failed to provide appropriate care. During the course of the investigation, APS substantiated the following: On 2/4/15, W2 noticed a large bruise on RV's foot when RV was seated in the shower chair waiting to be showered by W1. RV's right foot and ankle, from the small toe to hell, extending to the middle front of RV's ankle and back to RV's toe was blue, pink, green, and yellow in color, with noticeable swelling. This discoloration and swelling continued through 2/5/15. Although RP was told RV had a fall several days prior and hurt RV's toe, RP was not told of the injury and no incident report or progress notes discuss the injured area or how the injury occurred. RP's failure to supervise staff and ensure proper documentation is a violation of Oregon Administrative Rule. RP's failure to provide a safe environment is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +GP121012,514485,AFH,9/10/2012,"On or about September 5, 2012, Resident #1 (RV1) noticed that his/her laptop was missing from Resident #1_x001A_s room. Licensee reported the loss of resident property to the Department on September 10, 2012. Local law enforcement was also notified. The computer was not recovered. None of the visitors who had access to the home admitted to taking the laptop. The facility failed to protect Resident #1 from financial exploitation. The failure is a violation of Oregon Administrative Rule.",3,0,Not Substantiated,Substantiated,Financial abuse +RD118294A,514601,AFH,9/27/2011,"On or about October 3, 2011, it was reported that Licensee had failed to provide an adequate medication administration system. Resident #1 (RV1) was given an incorrect medication on September 27, 2011. RV1 did not sustain a negative outcome.",2,0,,, +RD118294B,514601,AFH,9/27/2011,"On or about October 3, 2011, it was alleged that Resident #1's (RV1) pain medication was not administered as ordered. It was determined that on September 28, 2011 and September 29, 2011, Reported Perpetrator #1 and Reported Perpetrator #2 gave RV1 medication in excess of the prescribed amounts, without first consulting RV1's medical provider. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB129114,514642,AFH,1/30/2012,"On or about January 30, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim #1 (RV1). It was determined through interviews that RV1 was removed from RP1's. Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) interfered with the removal of RV1 from the premises. The manner of this move-out resulted in stress for RV1. The licensee failed to provide a safe environment for RV1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM118578A,514717,AFH,11/29/2011,"It was reported that on or about November 29, 2011, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee failed to set up transportation for RV1 to return home from an appointment. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV118579,514717,AFH,11/29/2011,"It was reported that on or about November 29, 2011, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee stated that he/she would awaken RV1 by putting ice cold water on RV1's face. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Verbal/Mental abuse +MV120372,514717,AFH,6/19/2012,"It was reported that on or about June 19, 2012, Licensee failed to provide and adequate medication system. Resident #1 (RV1) haD an order for a medication, when his/her doctor ran a blood test to see if RV1 had been taking the medication, it was found that RV1 did not have any of the medication in his/her system.",2,0,,, +MV133782,514717,AFH,6/11/2013,"It was reported that on or about June 11, 2013, Licensee failed to provide a safe environment for Resident #1 (RV1). On June 11, 2013 Licensee and RV1 had an argument. Licensee threw some china and some flying shards of glass hit RV1 cutting the skin on his/her legs. Licensee's failures are a violation of Adult Foster Home (AFH) Oregon Administrative Rules (OARs) and is considered abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,,,Physical Abuse +CO12022,514726,AFH,12/5/2011,"On December 6, 2011, the licensor made an unannounced visit to the licensee_x001A_s Adult Foster Home (AFH) in response to a complaint. During the visit the licensor discovered that an unqualified caregiver (MS) provided transportation to Resident #1_x001A_s primary care physician and a walk-in-clinic for treatment of a wound. Resident #1 had multiple care needs that MS was not qualified to handle. MS did not have a current criminal records check, was not oriented to the home, and had not completed the caregiver preparatory workbook. The licensee failed to provide a safe environment for Resident #1. The licensee_x001A_s failure is a violation of Oregon Administrative Rules.",3,250,,, +KF118624,514726,AFH,12/4/2011,"On or about December 3, 2011, Resident #1 (RV1) fell at the Adult Foster Home (AFH) which resulted in a laceration 3cm long to RV1_x001A_s face and injury to RV_x001A_s chest. RV1 was not taken to the doctor for approximately 27 hours after the injury was discovered. The laceration required stitches, but because of the length of time that had passed after the fall, the sutures could not be done and the laceration had become infected. The licensee_x001A_s failure to intervene when RV1_x001A_s condition changed resulted in a negative physical outcome, is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,400,,,Neglect +MS116301A,514738,AFH,1/29/2011,"Resident #1 (RV1) required treatment for a skin wound. The Medication Administration Records (MAR) for RV1 indicated that no paste had been applied to RV1's coccyx on February 2, 2011 and February 7, 2011. Facility failed to provide treatment as ordered. Wrongdoing on the part of the licensee was substantiated.",2,0,,, +MS116301B,514738,AFH,1/29/2011,"Resident #2 was prescribed an antibiotic on January 29, 2011 to be given four times per day for 10 days. Licensee did not seek a crush order until January 30, 2011. Licensee failed to provide timely medical treatment.",2,0,,, +MV129063,514808,AFH,1/25/2012,Reported Perpetrator #1 (RP1) misinterpreted Resident #1's (RV1) physician's order for insulin. RV1 received too much insulin on more than one occasion.The exact number of occurrences could not be determined due to lack of appropriate documentation. There were no observable side effects to RV1. RP1 failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rule.,2,0,,, +MV148308,514808,AFH,8/27/2014,"On or around August 27, 2014, APS received an allegation that the facility failed to protect residents from inappropriate verbal comments and yelling. During the course of the investigation, APS determined that the reported perpetrator does raise his/her voice and/or yells at Residents 1 and 3. Due to these actions, the residents have felt sick, afraid, and/or are cautious around the reporter perpetrator. The facility failed to provide a safe environment for Residents 1 and 3. The failure is a violation of residents' rights and constitutes verbal/mental abuse.",2,,,,Verbal/Mental abuse +CO11148,514845,AFH,9/15/2011,"Licensor contacted the Adult Foster Home (AFH) on September 15, 2011. The licensor discovered that caregiver #1 did not have a completed caregiver preparatory workbook. Caregiver #1 was not a qualified caregiver and was left alone with residents on September 15, 2011. The licensee_x001A_s failure to ensure that a qualified caregiver was present and available in the foster home twenty-four hours per day on September 15, 2011 is a violation of the Oregon Administrative Rules (OARs).",3,250,,, +ES129287,514845,AFH,2/17/2012,"On or about February 17, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from involuntary seclusion. It was determined through interviews and observations that RV's bedroom had a reverse lock that allowed RV to be locked inside h/h bedroom. RV was heard calling for help to be let out of h/h bedroom and rattling the door knob. RV was locked in h/h bedroom for at least 30 minutes. Reported Perpetrator #2 (RP2) and RP1 were aware that RV had a lock on h/h door. The licensee failed to protect RV from involuntary seclusion. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Involuntary Seclusion +ES149322A,514845,AFH,11/17/2014,"It was reported that on or about November 17, 2014, Licensee failed to maintain an adequate medication system for Resident #1 (RV1). On November 13, 2014, Licensee and RP1 failed to ensure RV1 received his/her medication timely. Wrongdoing on the part of the Licensee was substantiated.",1,,,, +ES150643,514845,AFH,2/1/2013,"On or about March 23, 2015, the Department received a complaint which alleged Licensee (RP1) and Reported Perpetrator #2 (RP2) had wrongfully taken money from Resident #1 (RV). + + + +RV admitted to RP1_x001A_s adult foster home (AFH) in January 2013. The care plan developed by the facility for RV was dated January 17, 2013. Under _x001A_Cognitive Assessment_x001A_, the facility documented that RV was _x001A_not oriented, not aware of his/her (h/h) own needs, has memory deficits and is dependent on others due to h/h deficits_x001A_. + + + +The written agreement for care and services that RV entered into with RP1 was also dated January 17, 2013. The private pay contract indicated that RV would pay RP1 $4,000.00 per month. It also stated that RV would pay a one-time refundable deposit of $2,000.00. RV_x001A_s bank records verified that he/she had written a check on January 16, 2013 which satisfied the total move-in amount of $6,000.00 as agreed upon between RV and RP1. Additionally, RV also dispensed $950.00 to RP1. A notation on the check indicated that the $950.00 was for additional care to be provided by RP2. During the complaint investigation, Witness #4 (W4) reported that RP2 occasionally assisted other residents during the hours RP2 was being paid to provide care to RV. RP2 acknowledged that he/she had helped other residents but it was only a few times. + + + +Based on RV_x001A_s bank records, RV paid $2,500.00 per month for care provided by RP2. With the exception of the check written to RP1 on January 16, 2013, the remainder of the checks were written directly to RP2. RP2 acknowledged there was no written contact between RV and RP2. + + + +As part of the investigation, adult protective services also reviewed RV_x001A_s care records. A medical assessment dated January 24, 2013 documented that RV was diagnosed with progressive dementia. Hospice staff who monitored RV_x001A_s condition maintained care narratives. A number of entries made by hospice staff from February 1, 2013 through September 27, 2013 indicated that RV often answered questions in a _x001A_nonsensical_x001A_ manner, used jumbled or incoherent words and disjointed sentences. Witness #1 (W1), Witness #2 (W2), Witness #3 (W3), W4, Witness #5 (W5) and Witness #6 (W6) all reported that RV_x001A_s cognition was highly impaired. W3 also reported that he/she had specifically suggested to RP1 that she contact an independent company to become a conservator for RV. + + + +During the course of the investigation, W2, W3, W5, and W6 all reported that RP1 had mentioned throughout the months that RP1 and RP2 had experienced difficulty with RV not writing checks to them. RP1 and RP2 acknowledged that they began to have RV sign several blank checks at a time. RP1 reported that she would put the checks in front of RV and guide h/h hand to the signature line and he/she would sign them. RP1 stated that she would fill in the amounts as his/her payments became due. + + + +On the day RV died, there were two checks written from RV_x001A_s banking account. One check was written to RP1 in the amount of $2,000.00. A second check in the amount of $2,000.00 was written to RP2. RP1 reported that the checks had been written in the morning before RV died. However, hospice notes for October 2, 2013 indicated that _x001A_Pt [patient was] lying in bed and unresponsive_x001A_unable to swallow so AM tablet medications were not administered_x001A__x001A_ RP2 acknowledged to the investigator that the two checks written on October 2, 2013 had been completed using blank checks that RV had signed several weeks earlier. + + + +Based on the prior payments RV made to Licensee since he/she admitted to Licensee_x001A_s AFH thru RV_x001A_s death on October 2, 2013, Licensee had received payment for services thru October 16, 2013. The section in the private pay contract which provided that the provider would receive 15 days payment after the death of the resident would have been approximately satisfied by the pre-payment for services from October 2, 2013 thru October 16, 2013 during which no services were provided. Additionally, the provider had received a one-time refundable deposit in the amount of $2,000.00 when the resident admitted to Licensee_x001A_s AFH. The additional $2,000.00 check completed on October 2, 2013 meant that the Licensee had received approximately $4,000.00 more than what the terms of the contract allowed. + + + +During the course of the investigation, adult protective services also reviewed RV_x001A_s payment history to RP2. The investigator determined that RV pre-paid for RP2_x001A_s monthly services. The check written to RP2 on September 3, 2013 would have been for anticipated services provided thru October 2, 2013. RP2 had been paid in full when RV died on October 2, 2013. The check completed for $2,000.00 on or about October 2, 2015 was for services not yet provided, thus not owed to RP2. + + + +RP2_x001A_s conduct is considered financial exploitation and constitutes abuse. + + + +Licensee failed to assess and intervene as RV_x001A_s health status declined, failed to provide sufficient staffing for all residents, failed to provide a safe environment and wrongfully took RV_x001A_s assets. Licensee_x001A_s failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",4,800,Substantiated,Substantiated,Financial abuse +ES165356A,514845,AFH,3/31/2016,"RV is smoker, and on 3/31/16 was smoking outside when his pants caught on fire. Facility staff ran out, smothered the flames and doused RV's leg with water, but RV sustained serious burns. RV was transported to the hospital and then re-transported to a specialized burn unit. RV rolled his/her own cigarettes and facility staff were aware that RV's dexterity was poor, so RV's cigarettes were rolled loosely which caused burning tobacco and paper to drop. It was thought RV's pants fire was caused by dropped burning paper or tobacco. RV holds his/her own disposable lighters and cigarettes. RV's cognition is impaired, and in November, 2013, RV sustained burns when s/he could not get his/her undergarments off, so RV tried to burn them off with a lighter. The facility (Provider) did not assess RV's ability to safely and independently smoke unsupervised, despite indications RV could no longer smoke safely without supervision. The Facility has since closed.",4,,Substantiated,Substantiated,Neglect +ES165356B,514845,AFH,3/31/2016,"RV is incontinent of bowel and bladder, and frequently refuses and resists incontinence care. RV has cognitive deficits and does not always know when s/he is having an accident. RV's care plan does not address RV's behaviors or interventions. On 3/31/2016 RV2 cleaned RV after an accident, but gave RV a warm wash cloth to clean h/her own front genital area. RV2 reports that RV will grab h/her inappropriately if s/he tries to clean RV's frontal area. After this cleaning, RV was accidently burned and had to be transported the hospital, where dried feces and urine were found on RV. The facility has closed since this incident.",2,,Substantiated,Substantiated,Neglect +CO15045,514883,AFH,2/23/2015,Licensee and caregiver background checks had expired and no qualified caregiver was present.,3,500,,, +RD117611,514932,AFH,7/12/2011,"On or about July 13, 2011, it was reported that the Licensee failed to protect RV1 from diversion of medications. During a count of RV1's narcotic pain medication on July 12, 2011, it was found that forty to fifty tablets of RV1's narcotic pain medications were unaccounted for. Reported perpetrator #2 (RP2) admitted to taking forty tablets of RV1's narcotic pain medications for his/her personal use.",2,0,Not Substantiated,Not Substantiated,Financial abuse +CO14074,514932,AFH,4/22/2014,"Request for non-renewal. Licensee has now satisfied the remaining items to complete the renewal process. On 5/23/14, KK received an e-mail from Katie Mamic stating the LLA is withdrawing their request for NR. File closed.",3,,,, +ES128869,514942,AFH,1/6/2012,"On or about January 6, 2012, it was alleged that Reported Perpetrator#1 (RP1) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3). On 1/6/12 Reported Perpetrator #2 (RP2) quit h/her employment at RP1's adult foster home. When RP2 left the adult foster home, there was no other qualified caregiver on duty. RV1, RV2, and RV3 were left alone with no qualified caregiver for a period of time. RP1 admits that for a period of time, there was not a qualified caregiver on duty. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BO116139,514979,AFH,11/25/2010,"A concern was reported that Reported Perpetrator #2 (RP2) yells and uses curse words in the foster home. Resident #1 (RV1), Witness #2 (W2) and Witness #7 (W7) all indicated that RP2 does get irritated when others do not follow directions and may get upset and raise his/her voice. Witness #11 (W11) and RV1 stated that RP2 does swear in the foster home. RP2 failed to speak to all residents in an appropriate manner.",2,0,,, +RD120664,514979,AFH,6/22/2012,"Resident #1 requires the assistance of two caregivers when transferring to and from his/her bed, wheelchair and shower chair. Resident #1 hired and paid directly for a private caregiver. Licensee is scheduled to be at the foster home during the day so licensee is available to assist Resident #1's prviate caregiver with transfers. On more than one occasion, Resident #1's privately paid caregiver was left alone to provide care for all of licensee's AFH residents. At those times, a second person was not available and Resident #1 was unable to receive assistance with transfers, meals, bathing and repositioning in his/her bed until the licensee or another AFH caregiver arrived. The licensee failed to provide sufficient staff to provide appropriate care for all residents. The failure is a violation of Oregon Administrative Rule.",2,0,,, +GP116529,515011,AFH,3/15/2011,"On or about November 17, 2010, Witness #1 (W1) made a visit to the licensee_x001A_s adult foster home (AFH). W1 observed Reported Victim (RV) in a soiled brief with feces. Instruction was given to the caregiver on duty on proper cleaning and the risk of a urinary tract infection if RV is not properly cleaned. W1 informed caregiver that RV_x001A_s soiled briefs must be changed immediately. W1 discovered a stage III pressure sore 4cm long by 2.5cm wide and 1cm deep on RV_x001A_s left hip. The caregiver on duty had been delegated for wound care. + + + +On January 25, 2011, at approximately 3:30pm W1 made a visit to the licensee_x001A_s AFH. W1 found that RV_x001A_s peri area was red and RV_x001A_s diaper was soiled with feces and wet with urine through RV_x001A_s pants. RV stated to W1 that his/her diaper had been soiled since the morning. + + + +On February 10, 2011, W1 made a visit to the licensee_x001A_s AFH. RV had been complaining of pain in his/her coccyx. It was discovered that RV had a stage II pressure sore on his/her coccyx. W1 also observed 5-6 small wounds each approximately 0.5cm in diameter that were scattered over an area of approximately 4cm. The area was red and painful to the touch. The caregiver on duty was instructed on proper care of wounds and was instructed to do wound care daily and as needed. RV_x001A_s diaper was soiled with a large amount of feces and wet with urine. W1_x001A_s care plan for RV dated October 29, 2010, states that RV was a high risk for impairment of skin integrity. RV was admitted to a nursing facility on February 21, 2011, with a stage II pressure sore on his/her left buttock and a small stage II pressure sore on his/her coccyx. The licensee_x001A_s conduct constituted a failure to provide appropriate care to RV. The licensee_x001A_s failure is a violation of Oregon Administrative Rule and constitutes abuse.",3,400,,,Neglect +RS129043,515073,AFH,1/24/2012,"On or about January 24, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim #1 (RV1). It was determined through interviews and observations that RP2 failed to properly administer medication to RV1 which resulted in a potential risk of moderate harm. The licensee's failure is a violation of Oregon Administrative Rules.",2,0,,, +AL145680,515091,AFH,3/27/2013,"It was reported that on or about March 27, 2013, Licensee failed to protect residents from inappropriate verbal comments and harassment. Reported Perpetrator #2 (RP2) would yell, scream, harass, and physically threaten residents on a daily basis. Licensee had knowledge of RP2's and has previously approached RP2 regarding his/her inappropriate behaviors toward all residents. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee and RP2 was substantiated.",2,,Substantiated,Substantiated,Verbal/Mental abuse +CO13088,515102,AFH,7/17/2013,"On June 18, 2013, the Department was notified that the Local Office had received a Final Fitness Determination on June 17, 2013, indicating Licensee_x001A_s background check had been denied. Licensee_x001A_s failure to maintain qualification requirements to operate an Adult Foster Home (AFH) is a violation of Oregon Administrative Rules; Licensee_x001A_s failures have threatened the health safety and well-being of residents.",3,0,,, +MF118570,515223,AFH,11/30/2011,"It was alleged that on or about November 30, 2011, Licensee failed to provide Resident #1 (RV1) the appropriate oral care. RV1 was physically unable to adequately perform oral hygiene care independently. Licensee failed to provide adequate oral hygiene care to RV1. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +CO13105,515223,AFH,8/13/2013,Licensee had an unqualified caregiver (caregiver #1) working unsupervised in his/her AFH. Caregiver #1 had been working in Licensee's AFH unsupervised and had not yet completed the required caregiver preparatory workbook.,3,250,,, +MS135410,515223,AFH,12/16/2013,"It was reported that on or about December 16, 2013, Licensee failed to provide appropriate care to Resident #1. Licensee failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MF147951B,515223,AFH,7/30/2014,"Nedical records indicated a 12/13/13 doctor's order for a pain medication to be administered four times daily. On 6/20/14, the facility contacted the doctor to state that administering the pain medication four times daily resulted in Resident 1 appearing ""sedated"". The Medication Administration Record (MAR) indicates that the facility listed the ordered frequency on the MAR in May and June as four times daily (per the order) but administered the pain medication three times daily for those two months. The doctor order was changed on 7/8/14 to have the same pain medication administered three times daily instead. There was no observable negative outcome but the facility failed to follow the prescribing practitioner's order. This failure is a violation of Oregon Administrative Rules.",2,,,, +MF150446,515223,AFH,3/3/2015,"On or about March 3, 2015, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RV has mental and physical disabilities which makes RV dependent on others. RV stated that RP has told RP ""I hate you."" RP acknowledged that occasionally when RV is demanding RP tells RV ""I need to do (whatever else is going on) first"" and ""you just want attention."" RV stated that he/she did not want to return to the facility and that he/she is just at the facility ""waiting to die."" The licensee failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MF150818,515223,AFH,4/6/2015,"On or about April 7, 2015, it was alleged that Reported Perpetrator (RP) failed to administer RV's medication as ordered. RV is prescribed Mapap 500mg two tablets to be administered every 8 hours. RV's medication administration record (MAR) notes that RV received the medication every 6, 7 and 11 hours apart. RP acknowledged that he/she had not been administering the medication as ordered. The licensee failed to administer the medication as ordered. The failure is violation of Oregon Administrative Rules.",2,,,, +MV147389,515287,AFH,6/12/2014,"On or about June 12, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from financial exploitation. Reported Perpetrator #3 (RP3) acknowledged that he/she accepted $1000 cash from RV. RV did not recall giving RV $1000.",2,,Not Substantiated,Substantiated,Financial abuse +CO14135,515295,AFH,7/8/2014,Smoke alarm in Licensee's childs room did not have a battery in it and did not sound when tested. FOP sent,3,250,,, +CO12036,515303,AFH,1/5/2012,Failure to have a qualified caregiver present and available 24-hours per day and failure to comply with the Oregon Indoor Clean Air Act.,2,400,,, +MV151335,515303,AFH,5/13/2015,"On or about May 19, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV1) and Resident #2 (RV2) from theft of assets. During the course of the investigation, APS substantiated that RV1 was missing approximately 12 tablets of one of his/her medications. APS also determined that RV2 was missing approximately $150 from his/her bag that was kept under RV2_x001A_s bed. APS observed that resident medications are kept in a locked box inside an unlocked closet located near the facility_x001A_s front door. The key to the medication box was laying on top of the box. One or more individuals had the opportunity to access the box of medications as staff, residents and visitors from this AFH moved freely between the three facilities operated by the same Licensee. It is unclear who took RV1_x001A_s medications and RV2_x001A_s money. The wrongful taking of assets, funds, property or medications belonging to a resident is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +CO15224,515322,AFH,11/9/2015,Failed to have an approved background check for caregiver C.S. who worked alone with residents.,3,250,,, +RD134793B,515367,AFH,9/8/2013,"On or about September 10, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RV was addmitted to RP's adult foster home (AFH) at the end of August. RP instructed RV to not yell for help if he/she needs assistance at night. As an alternative the first few nights RV called RP's cell phone to get assistance. During that time period RP yelled at RV, was disprespectful and spoke to RV rudely and told RV not to call RP at night and lose RP's cell phone number. As a result RV felt intimidated. Witness #1 (W1) heard RP talking to RV in a ""raised"" voice and observed RV crying after RP talked to RV. The licensee failed to protect RV from inappropriate verbal comments. The failure is a violation of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +RD134793A,515367,AFH,9/8/2013,"On or about August 29, 2013, Resident #1 (RV) was admitted to the licensee's (RP) adult foster home (AFH). RV's care plan dated 9/13/2013 documents that RV is incontinent of bowel and bladder, needs to be changed four times a day and requires two people to assist. Under night needs, it is documented that RV would like to be turned every two hours and to be changed four times per day. RV's health issues included skin integrity that was to be monitored weekly by an RN. RV's screening assessment dated 8/27/2013 documents RV's paralysis of the lower body. RP did not have a call system in place for RV's night needs. RV was instructed by RP to not yell for help at night because RP did not want RV to wake up other residents. Throughout the first week, RV was not getting his/her briefs changed or repositioned between the hours of 7:00pm and 8:00am. RV stated that on one occasion he/she had sat in his/her own feces for twelve hours without being changed. RV stated that he/she could smell the feces but could not feel it due to RV's paralysis of the lower body. RV was told by RP that none of RP's staff would be getting up during the night to change RV. Witness #1 (W1) stated that he/she asked RP about re-positioning RV during the night and RP's stated that that was not how his/her AFH was ran. + + + +RP had a hoyer lift to assist the caregiver in re-positioning/transferring RV. RV preferred that caregivers not use the hoyer lift and instead use a draw sheet to reposition RV. Witness #3 (W3) stated that he/she would not use the draw sheet because W3 did not want to injure his/her back. If RV refused to allow W3 to use the hoyer lift then W3 refused to re-position RV while he/she was working. The licensee failed to provide appropriate care and services to RV. The licensee's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse. UPDATE: FOD completed 6/5/14. E-mail sent to AR requesting they begin the aging process.",3,400,,,Neglect +RD145888,515367,AFH,1/26/2014,"On or about January 27, 2014, it was alleged that Reported Perpetrator #1 (RP1#) failed to provide a safe environment for Reported Victim (RV). Witness #2 (W2) observed Reported Perpetrator #2 (RP2) telling RV that RV could not have water on multiple occassions. W2 observed RP2 telling RV that RV had to stay in bed until the morning. W2 observed RP2 yell at RV to stop playing with RV's television remote controls. RV reported to W1 that RP2 yells and cusses at RV and RP2 witholds water from RV. RV stated that he/she is afraid of RP2. RP1 had received a complaint approximately two weeks ago resulting in a ""disciplinary"" talk with RP2. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RD146191,515367,AFH,2/26/2014,"On or about February 26, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2) from misappropriation of medication. During an interview with law enforcement Reported Perpetrator #2 (RP2) acknowledged taking narcotic pain medication from RV1 and RV2. RP2 replaced approximately 100 of RV1's bottled narcotic pain pills with over the counter pain pills. RP2 replaced approximately 15-30 of RV2's narcotic pain pills with over the counter pain pills.",3,,Not Substantiated,Substantiated,Financial abuse +RD149463,515367,AFH,11/29/2014,"On or about December 2, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a home-like environment for Reported Victim (RV). RV's Behavior Plan dated 7/15/2014 notes that RV becomes agitated towards staff and others, yells, curses at caregivers. RV's careplan directs caregivers to not argure with RV, walk away from RV and give him/her time to calm down. The careplan notes to respond by being sensitive and have patience while RV is dealing with loss of independence and try to engage in meaningful conversations. During the weekends of 11/22/2014-11/23-2014 and 11/28/2014-11/29/2014, RV became argumentative and combative toward Reported Perpetrator #2 (RP2). RP2 continued to engage RV by roughly grabbing an item that RV was using to try and hit RP2. Additionally Witness #3 (W3) observed RP2 shake RV's arm roughly during the same incident. W3 witnessed RP2 come to RV's doorway and refused to leave upon RV's and W3's request. RP2 failed to foloow RV's care plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO11036,515385,AFH,3/17/2011,Licensee admitted to sexually abusing an AFH resident on multiple occasions.,4,0,,,Sexual abuse +MF116546,515385,AFH,3/17/2009,"It was reported on or about March 17, 2011, the Licensee failed to protect Resident #1 (RV1) from inappropriate sexual contact. Reported Perpetrator #1 (RP1) admited to having inappropriate sexual contact with RV1 while RV1 resided at the Adult Foster Home. Interviews concluded that wrongdoing on the part of the Licensee was substantiated.",3,0,Substantiated,Substantiated,Sexual abuse +HB134548A,515410,AFH,9/27/2013,"It was reported that on or about September 27, 2013, Licensee failed to provide adequate care for Resident #1 (RV1). RV1 needed blood draws as a precautionary measure related to a medication he/she was prescribed. The blood draws were to help medical professionals to determine the amount of medication RV1 should have received. Reported perpetrator #1 and Reported Perpetrator #2 were very difficult to reach for the scheduling of RV1's blood draws causing RV1 to miss his/her blood draws as needed. This resulted in RV1's medication being held until further notice. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,,,, +HB134548B,515410,AFH,9/27/2013,"It was reported that on or about September 27, 2013, Licensee failed to provide a safe medication administration system. Reported Perpetrator #2 (RP2) continued to sign Resident #1's (RV1's) medication administration records (MARs) for a medication that had been discontinued, failed to initial MARs and failed to administer medications as ordered. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,,,, +HB135170A,515410,AFH,11/22/2013,"It was reported that on or about November 22, 2014, Licensee failed to provide adequate supervision for Resident #1, Resident #2, and Resident #3. It was discovered that Reported Perpetrator #2 (RP2) attempted to harm himself/herself at the facility and as a result was hospitalized and was unable top provide supervision to the residents in the home. RP2's failures are considered neglect and constitute abuse.",3,,Not Substantiated,Substantiated,Neglect +HB154000,515410,AFH,12/21/2015,"Licensee failed to prevent the theft of Resident #1's medications, Licensee's failures are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,Substantiated,Substantiated,Financial abuse +CO16113,515410,AFH,12/19/2015,"On December 21, 2015, Adult Protective Services (APS) initiated an investigation into the theft of Resident #1_x001A_s (_x001A_RV1_x001A_) narcotic pain medications. RV1 was ordered by his/her physician to take eight narcotic pain medication pills per every 24 hour period. On November 18, 2015, facility staff counted RV1s narcotic pain medication pills and there were 610 pills. On December 7, 2015, 224 additional narcotic pain medication pills were delivered to the AFH for RV1. On December 18, 2015, at approximately 5:30 PM, facility staff conducted a medication count of RV1s narcotic pain medication pills and there were only 368 pills accounted for. Licensee was immediately notified regarding the unaccounted for narcotic pain medication pills. On December 22, 2015, facility staff conducted the first narcotic pain medication count since December 18/2015 and created a narcotic count sheets for each bottle of RV1s narcotic pain medication. On December 22, 2015, the narcotic pain medication count was 189, indicating additional unaccounted for narcotic pain medication pills pf approximately 150 since December 18, 2015.",4,,Substantiated,Substantiated,Financial abuse +CO13108,515578,AFH,7/30/2013,"Licensee failed to develop resident records for a sixth resident admitted beyond AFH classification, failed to keep current medicationd administration records, failed to have a medication administration record for Resident #5, and failed to ensure Christine Pace had a cleared criminal background check prior to having access to resident records..",3,150,,, +CO13141,515578,AFH,12/6/2013,Licensee failed to provide a safe medicaiton administration system.,3,150,,, +NB135272B,515578,AFH,12/1/2013,"It was reported that on or about December 1, 2013, Licensee failed to maintain a safe medication administration system for all resident. Licensee was observed popping Resident #1's missed medications out of his/her bubble packs and attempting to hide the missed medications. Licensee continued to administer medication after they were discontinued and without a doctors order. Licensee failed to administer medications as ordered by the doctor. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the licensee was substantiated.",2,,,, +NB135272C,515578,AFH,12/1/2013,"It was reported that on or about December 1, 2014, Licensee failed to provide a safe environment for Resident #1. Licensee had been heard yelling at Resident #1 and also admitted to yelling at Resident #1. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO15215,515578,AFH,10/7/2015,Voluntarily surrendered - Non-renewal not needed.,4,,,, +NB153034A,515578,AFH,10/3/2015,"On or about October 5, 2015, the Department received a complaint which alleged Licensee (RP1) had failed to protect Resident #1 (RV1) from inappropriate verbal communication. During the course of the investigation, Witness #1 (W1) reported that he/she had heard RP1 yell at RV1, ""Get to your room"". RP1 had wanted RV1 to take a nap. RV1 did not want to take a nap and came out of his/her room. W1 further reported that RP1 had said, ""I could break your fucking neck and you know I'd do it. The Adult Protective Services Specialist (APSS) asked RV1 if RP1 yelled at him/her. RV1 responded in the affirmative when asked on two different occasions. Licensee failed to protect RV1 from inappropriate verbal interactions and threats. Licensee's failure is a violation of resident rights and constitutes verbal/emotional abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +NB153034B,515578,AFH,10/3/2015,"On or about October 5, 2015, the Department received a complaint which alleged Licensee (RP1) had failed to provide appropriate care and services for Resident #2 (RV2) and Resident #3 (RV3). + + + +During the course of the investigation, the Adult Protective Services Specialist (APSS) reviewed documents related to RV2 and RV3. RV2 and RV3 had been admitted to RP1_x001A_s adult foster home on or about September 24, 2015. + +RV2_x001A_s hospital records indicated that on or about September 23, 2015, RV2 could follow simple commands, ask simple questions, had been getting in and out of bed and could move satisfactorily using a walker. Witness #2 (W2) reported that within three days after RV2_x001A_s admission to the AFH, RV2 had experienced a significant decline and was in pain. Despite the change in RV2_x001A_s condition, RP1 did not contact RV2_x001A_s family. The facility was unable to produce documentation that a pre-admission screening and assessment had been conducted and there were no resident narratives, other than a statement which indicated that RV2 had passed away on October 4, 2015. + +APSS also reviewed documents related to RV3. RV3_x001A_s assessment dated September 23, 2015 indicated that RV3 did not require assistance with eating and the part of the assessment related to mobility indicated that RV3 was not bedbound. W2 reported that RV3 was able to sit up and talk the first day or two upon admission and that RV3 required minimal assistance with eating. After those initial two days, W2 stated that RV3 was in bed all of the time and couldn_x001A_t feed him/herself. RV3_x001A_s medical professional was not contacted until October 5, 2015, the day before RV3 died. + +Licensee failed to notify RV2_x001A_s family and RV3_x001A_s primary care physician as required whenever a resident experiences a change in condition. Licensee_x001A_s failure to provide a safe environment is a violation of residents_x001A_ rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +NB153034C,515578,AFH,10/3/2015,"On or about October 5, 2015, the Department received a complaint which alleged the facility had failed to maintain a safe medication administration system. During the course of the investigation, the Adult Protective Services Specialist (APSS) discovered the following: Medications for RV1, RV2 and RV3 were not administered as ordered; Medication Administration Records (MARs) for RV1 and RV3 were not accurate; and documentation regarding the disposal of resident medications, including controlled substances was insufficient. Licensee failed to maintain a safe medication administration system. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,,, +NB153034D,515578,AFH,10/3/2015,"On or about October 5, 2015, the Department received a complaint which alleged the facility had failed to provide a safe environment for Resident #1 (RV1). RV1 had a history of exit seeking behavior. This behavior was documented in RV1_x001A_s Care Plan dated May 10, 2015. During the course of the investigation, the Adult Protective Services Specialist (APSS) reviewed a number of records related to RV1. An Incident Report dated May 16, 2015, documented that the Licensee had called an alarm company to ascertain what kinds of alarms are available to put on doors. The entry also mentioned that, _x001A_We will follow up on this_x001A_. On May 20, 2015, the facility was unaware that RV1 had eloped. Based on information contained in this APS report, RV1 was located by staff approximately 0.30 miles from home. An entry dated May 28, 2015, stated that, _x001A_RV1 needs to be monitored all the time_x001A_. On August 20, 2015, RV1 eloped again and was returned to the facility by law enforcement. On September 25, 2015, RV1 left the facility unattended. When RV1 was located, he/she was wearing slipper socks, not shoes. Licensee failed to sufficiently supervise RV1 and failed to put adequate interventions in place to prevent RV1 from eloping. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +NB153034F,515578,AFH,10/3/2015,"On or about October 5, 2015, the Department received a complaint which alleged the facility had confined Resident #1 (RV1) to his/her room. During the course of the investigation, Witness #1 (W1) reported that he/she had heard Licensee (RP1) yell at RV1, _x001A_Get to your room_x001A_ and _x001A_close your door_x001A_. RP1 wanted RV1 to take a nap at approximately 4:45pm. Witness #3 (W3) reported that it was not normal for RV1 to take a nap at that time of day. RV1 came out of his/her room on multiple occasions and RP1 consistently returned RV1 to his/her room. RP1 acknowledged that she told RV1 that _x001A_you are going to lay down and take a nap_x001A_. RP1 also acknowledged that she waited out in the hallway because she knew that RV1 was going to exit his/her room again. The investigation concluded that RP1 restricted RV1 to his/her room. Licensee_x001A_s conduct is a violation of resident rights, is considered involuntary seclusion and constitutes abuse.",2,,Substantiated,Substantiated,Involuntary Seclusion +KF116642,515606,AFH,3/14/2011,"On March 14, 2011 the RV had been left alone at RP's adult foster home. While alone, the RV experienced a fall and could not get up. RV was found by W4 who called emergency services. RV was transported to a medical facility which found signs of dehydration and a subdural hematoma. The investigation determined that the Licensee had failed to provide appropriate care. This failure violates resident rights, is considered neglect, and constitutes abuse.",3,0,,,Neglect +CO12083,515613,AFH,8/1/2012,"Licensee failed to maintain a safe medication administration system, failed to have a qualified caregiver present and available in the foster home 24-hours per day, seven days per week, failed to hire an approved Resident Manager when not living in the AFH, failed to conduct resident pre-admission screenings, failed to prepare and update care plans and narratives in a timely manner, failed to maintain minimum standards for the interior and exterior of the foster home, failed to conduct timely evacuation drills, and failed to have ensure all animals living at the foster home were current with their vaccinations.",3,0,,, +RB120679A,515613,AFH,7/24/2012,"On or about July 30, 2012, multiple medication system issues were identified. Scheduled medications were observed to be unsecured and in containers other than the pharmacy dispensed bottles. The containers did not have resident names or the time(s) of day the medication was to be given. The ""as needed"" (PRN) medications were in a locked cabinet that was unable to be accessed by the caregiver and would not have been available if a resident had needed and requested them. A review of the residents' Medication Administration Records (MARs) found that the documents had been completed in advance of a medication pass rather than correctly initialed at the time the medication was dispensed. The MAR for Resident #2 (RV2) did not accurately reflect RV2's current narcotic prescription. The facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RB120679B,515613,AFH,7/24/2012,,3,0,Not Substantiated,Substantiated,Financial abuse +NB147353,515617,AFH,6/11/2014,"Resident #1 (RV1) had a credit card issued by Chase Bank. RV1 had not used his/her account recently and had maintained a zero balance owing for quite some time. On or about June 11, 2014, Chase Bank contacted Witness #1 (W1) and requested a payment in full for the balance owing on RV1_x001A_s account which was approximately $13,000. W1 disputed the charges with Chase Bank, completed a fraud report with the bank and filed a police report. + + + +The charges began in September of 2013. A representative from Chase Bank told W1 that a female had called the bank and reported that RV1_x001A_s card had been lost and requested a replacement be sent to the address of the Licensee_x001A_s adult foster home (AFH). W1 stated that he/she had never requested Chase Bank to issue a replacement card. After a few months of not receiving a payment, Chase Bank called the AFH but was told by a male that RV1 had passed away which was untrue. + + + +W1 suspected Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) may have used the card. Reported Perpetrator #2 stated that he/she did not recall a credit card being delivered to RV1 at the AFH. RP2 denied ever using RV1_x001A_s credit card. RP3 failed to contact the Department and was never interviewed. + + + +The evidence gathered during the Department's investigation failed to specifically link RP2 and/or RP3 to the unauthorized use of RV1_x001A_s credit card. The responsibility for the financial exploitation has been apportioned to an unknown individual. The facility failed to provide a safe environment. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Financial abuse +CO14189,515617,AFH,9/18/2014,Advisory letter regarding compliance with medication administration prepared and may be found in I:/CA Team/2014/AFH/Letters.,2,,,, +NB148587,515617,AFH,9/13/2014,"On or about September 18, 2014, the Department received a complaint which alleged that Resident #1 (RV) did not receive his/her pain medications. RV had written orders for two narcotic pain medications. A refill was ordered on or about September 10, 2014. RV_x001A_s last available dose of narcotic pain medication #1 was dispensed on September 15, 2014. RV_x001A_s last available dose of pain medication #2 was administered on September 13, 2014. On September 15, 2014, the facility called the pharmacy to check on the status of the order. The facility was told that the order had been delivered on September 13, 2014 and that Reported Perpetrator #2 (RP2) had signed for delivery of the medications. The medication was not located at the facility. RV experienced pain as a result of not receiving his/her medications. + +Responsibility for the loss of medication has been apportioned to RP2. RP2_x001A_s conduct is considered financial exploitation and constitutes abuse. + +Licensee failed to provide a safe medication administration system. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Financial abuse +CO16042,515617,AFH,2/24/2016,"During a renewal inspection on 2/24/16, the LLA found missing carbon monoxide alarm and missing smoke detector, as well as one smoke alarm dismantled and another with batteries removed. Mandatory civil penalty issued.",3,1050,,, +CO13107,515656,AFH,8/8/2013,Licensee haad been opperating his/her AFH as the sole caregiver with an expired criminal records clearance one night a week.,3,250,,, +CO15192,515696,AFH,9/8/2015,for falsification of facility records. non-compliance regarding regarding resident records and medication administration.,3,1000,,, +CO15218,515696,AFH,10/19/2015,,2,,,, +MS152598,515696,AFH,8/26/2015,"It was reported that on or about August 26, 2015, Licensee failed to provide an adequate medication administration system. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +MS105435A,515698,AFH,10/8/2010,"On or about October 2010, it was alleged that Reported Perpetrator (RP) was unable to account for Reported Victim's (RV) medications. The medication administration records in addition to the original drug destruction document, the modified drug destruction document, and the hand written medication count sheets do not add up to the amount of pills dispensed by the pharmacy for RV. There are approximately 292 to 297 anti-histamine pills unaccounted for as well as an indeterminent amount of narcotic pain pills as Licensee stated she returned these to the pharmacy. The pharmacy has no record of such return and it is against the law for pharmacy to take back scheduled medications which includes narcotic pain medications.",2,0,,, +MS105435B,515698,AFH,10/8/2010,"On or about October 8, 2010, it was alleged that Reported Perpetrator (RP) failed to assess and intervene when Reported Victim (RV) condition changed. RV was found to be lethargic and then became non-responsive to the RP and Caregiver 1 at approximately 10:00am. RP contacted RV's family at 12:45pm who advised RP to call 9-1-1. Emergency services were contacted at 12:46pm and RV was transported to the hospital for weight loss, fatigue and malaise. RP failed to intervene when there was an obvious change in RVs condition.",2,0,,,Neglect +MS105435C,515698,AFH,10/8/2010,"On or about October 8, 2010, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. It was determined that RP humiliated, yelled at and threatened RV. RP failed to protect RV from verbal abuse.",2,0,,,Verbal/Mental abuse +MS105435D,515698,AFH,10/8/2010,"On or about October 8, 2010 it was alleged that Reported Perpetrator (RP) failed to provide or assist Reported Victim (RV) with hygiene. It was determined that RP failed to provide appropriate oral hygiene. RP failed to ensure RV brushed RV's teeth with toothpaste. RP acknowledged staff had fallen behind on oral care.",2,0,,,Neglect +MS118612,515698,AFH,11/30/2011,"On or about November 30, 2011, Resident #1 (RV1) received incorrect medication. Reported Perpetrator #1 (RP1) contacted the poison control center to report the incident and for further instruction. RP1 was advised to withhold RV1_x001A_s pain medication and to contact RV1_x001A_s physician the following morning. The licensee failed to provide a safe medication administration system which placed RV1 at risk of serious harm. The failure is violation of Oregon Administrative Rule and constitutes abuse. NOTE: 1/3/13 Final Order by Default completed. Sent to AR person to start aging process.",3,450,,,Neglect +MS121899,515698,AFH,12/10/2012,"On or about December 10, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV was prescribed compression stockings on 11/21/12. RP did not fax the prescription to the pharmacy for four days. RP was notified the prescription would not be covered by insurance on 11/28/12. It was understood by RP that Witness #2 (W2) provided financial assistance for anything that RV would need that insurance would not cover. The pharmacy contacted RP on 12/12/12 and notified RP that RV's prescription was filled and ready for pick-up. On 12/12/12 Witness #4 (W4) contacted W2 and notified h/h that RV had a prescription for compression stockings and that it was not covered by RV's insurance. W2 had no knowledge of the prescription until W4 contacted W2. W2 e-mailed RP and sent the money for RV's compression stockings on 12/13/12. RP received the money on 12/14/12. RV's compression stockings were not picked up until 12/18/12.",2,0,,,Neglect +CO13053,515698,AFH,3/12/2013,"On June 1, 2011, the licensor had a telephone conversation with the licensee regarding registered nurse HG. The licensee was informed that she needed to allow registered nurse HG access to the adult foster home (AFH) and to cooperate with HG. On or about 3/8/2013 the licensor was informed by registered nurse HG that the licensee refused HG access to the residents at the AFH. HG called the AFH 1.5 hours prior to the visit and left a message. HG did not receive a return call from the licensee to decline the visit. Upon entering the AFH HG made contact with the licensee. The licensee stated that HG was no longer the nurse at the AFH and _x001A_to get out of my house! I don_x001A_t want you to touch any of my patients._x001A_ + + + +On March 12, 2013, the licensor made a visit to the licensee_x001A_s AFH. The licensor issued a violation for not cooperating with registered nurse HG. The licensee failed to cooperate with the registered nurse. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. UPDATE 7/26/13: FOD sent this date, emailed AR to begin aging process.",3,200,,, +MS148867,515703,AFH,10/7/2014,"On or about October 9, 2014, Adult Protective Services received an allegation that RP failed to protect resident from rough treatment. During the course of the investigation, APS determined that RV had two incidents of bowel incontinence and became combative with staff when staff attempted to clean RV and RV's room. RP restrained RV by holding RV's arms down in order to prevent RV from injurying self and/or staff. RP used only the amount of force necessary to restrain RV, but this restraint did inflict bruising upon RV. RV did not appear to suffer ill effects and does not appear fearful of staff. RP's use of restraints was in violation of OAR and did cause RV physical injury. RP's failure resulted in a violation of resident rights and is considered physical abuse.",2,,,,Physical Abuse +HB105791,515731,AFH,12/7/2010,"On or about December 7, 2010, a report was received alleging that the Licensee had failed to provide a safe environment for Resident #1. Resident #1's care plan indicated he/she had a history of elopement. Resident #1 left the facility unattended on the afternoon of November 22, 2010. Resident #1 was found approximately four blocks away and was brought home by law enforcement. The alarm on the front door was identified at that time as being broken. On the morning of November 23, 2010, Resident #1 had again left the facility unattended and was found about one block away near a creek. The alarm had not been fixed. The investigation concluded that Resident #1 had been exposed to harm.",2,0,,, +ES116136,515753,AFH,12/22/2010,Witness #1 (W1) mailed Resident #1 (RV1) a $50 Wal-Mart gift card for Christmas. RV1 never received the giftcard from W1. The card was observed being used by Witness #4 (W4). Reported Perpetrator #2 (RP2) admitted to Witness #3 (W3) that he/she took the gift card and gave it to W4. RP2 indicated that he/she took the card to give W4 a Christmas present and that money was tight.,2,0,Not Substantiated,Substantiated,Financial abuse +ES118591,515753,AFH,12/1/2011,"It was reported that on or about December 1, 2011, Licensee failed to provide appropriate care to Resident #1. Reported Perpetrator #2 (RP2) failed to follow physician's orders for one of Resident #1's ordered medications. As a result Resident #1's medical condition was not healing as it should. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES151439,515753,AFH,5/26/2015,"On or about June 2, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to provide basic care to RV. During the course of the investigation, APS determined the following occurred: RV moved into RP1's facility. RP1 failed to ensure that RV's medications upon discharge were properly transcribed on the facility Medication Administration Record (""MAR""). Blood glucose levels were not charted per doctor orders. RV did not have a self-administer order for injections, but was allowed to self-administer injections. No caregivers in the facility were delegated to administer injections for RV. The kitchen was closed to all residents in the evening. When RV expressed sentiments regarding having a roommate he/she was told to deal with it or that he/she could move. RV does not feel that he/she had choices adequately explained to him/her regarding moving into another facility. APS substantiated wrongdoing. RP1's failure to provide basic care is considered a violation of both resident rights and Oregon Administrative Rules, is considered neglect, and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +CO15190,515753,AFH,9/3/2015,"On or about January 23, 2015, the local licensing authority (""LLA') conducted a renewal visit inspection. During the course of the inspection, the LLA determined that there is no primary caregiver living in the Adult Foster Home (""AFH""). According to LLA this has an ongoing problem for the last four years. This penalty has been aggravated based on the length of time the violation continued uncorrected.",2,300,,, +CO15207,515753,AFH,9/30/2015,,2,,,, +CO15208,515753,AFH,9/30/2015,,2,,,, +CO15239,515761,AFH,11/24/2015,Provider did not have Carbon monoxide alarm within 15 ft of bedroom of resident area or provider's bedrooms. Also has resident records issues.,3,450,,, +MV150427A,515784,AFH,3/27/2014,"It was reported that on or about March 27, 2014, Licensee failed to protect Resident #1 from involuntary seclusion. Reported Perpetrator #1 (RP1) allowed Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) to keep Resident #1 (RV1) up in his/her wheelchair in the common area of the house, against RV1 wishes, in order to prevent RV1 from napping during the day because RV1 is up all night. Licensee's failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MV151336,515784,AFH,5/13/2015,"On or about May 19, 2015, the Department received a complaint which alleged the facility had failed to maintain an adequate medication system. During the course of the investigation, APS substantiated that Resident #1 (RV1), Resident #2 (RV2) and Resident #3 (RV3) were each missing one or more medications. APS also determined that resident medications are kept in a locked box inside an unlocked closet located near the facility_x001A_s front door. The investigator observed that the key to the medication box was laying on top of the box. One or more individuals had the opportunity to access the box of medications as staff, residents and visitors from this AFH moved freely between the three facilities operated by the same Licensee. It is unclear who took the medications. Theft of medications is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +RB132276,515800,AFH,1/15/2013,"Resident #1 experienced a fall on or about January 14, 2013. The next morning Resident #1's left arm was swollen and bruised. Resident #1 was transported to the hospital and was determined to have sustained a broken left arm. On January 30, 2013, Licensee acknowledged that Resident #1 had fallen several times in the past. Resident #1's care plan dated December 15, 2012 did not reflect that Resident #1 was a fall risk. Licensee failed to intervene when Resident #1's condition regarding falls had changed and failed to put interventions in place. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,400,,,Neglect +CO13020,515801,AFH,12/18/2012,"On November 30, 2012, the licensor conducted an unannounced visit to the licensee_x001A_s Adult Foster Home (AFH). During part of the visit the only caregiver on duty was RM. The licensor discovered that RM did not have an approved criminal records check. The licensor also found that RM had not completed the caregiver preparatory work book or AFH orientation as required. The licensee failed to provide a safe environment. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. On November 30, 2012, the licensor conducted an unannounced visit to the licensee_x001A_s AFH. During the visit the licensor found that a smoke alarm was not installed in bedroom #2. The licensee failed to provide a safe environment. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. + +On November 30, 2012, the licensor made an unannounced visit to the licensee_x001A_s AFH. During the visit the licensor found that the Medication Administration Record (MAR) was not initialed for Resident #1 as required on 11/26/12, 11/27/12, 11/28/12, 11/29/12, and 11/30/12. Resident #2 MAR was not initialed as required on 11/30/12. Resident #3 MAR was not initialed as required on 11/29/12 and 11/30/12. The licensee failed to provide a safe medication administration system. The licensee_x001A_s failure is a violation of Oregon Administrative Rules. + + + +On August 30, 2012, the licensor made an unannounced visit to the licensee_x001A_s AFH. During the visit the licensor discovered that the MAR for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 did not contain a legible signature for the month of August 2012. The licensee failed to provide a safe medication administration system. The licensee_x001A_s failure is a violation of Oregon Administrative Rules. + + + +On April 18, 2012, the licensor made an unannounced visit to the licensee_x001A_s AFH. During the visit the licensor found that the MAR for Resident #1 was not initialed as required on 4/7/12, 4/13/12, 4/14/12, and 4/17/12. Resident #2 MAR was not initialed as required on 4/7/12, 4/13/12, 4/14/12, and 4/17/12. Resident #3 MAR was not initialed as required on 4/7/12, 4/13/12, 4/14/12, and 4/17/12. The licensee failed to provide a safe medication administration system. The licensee_x001A_s failure is a violation of Oregon Administrative Rules. NOTE: 4/16/2013 FOD drafted this date. Email sent to AR to begin aging process.",3,650,,, +JG117544,515816,AFH,4/20/2011,"On or about June 30, 2011 it was reported that RV had been having behaviors and RP2 was told to take RV to the doctor for three months, but hasn't and RV's behaviors were increasing. RP2 had been giving RV a medication that had been discontinued.",2,0,,, +JG117789A,515816,AFH,5/26/2011,"On or about May 26, 2011 it was reported that Licensee failed to provide a safe environment. RP3 would throw bean bags at RV",2,0,,, +CO12033,515816,AFH,4/27/2012,"A monitoring visit was conducted at Licensee's adult foster home (AFH) on April 5, 2012. Licensor determined that the caregiver on duty did not have an approved criminal records check. Licensee's failure to ensure a safe environment is a violation of Oregon Administrative Rule.",3,250,,, +BH146604B,515887,AFH,12/15/2012,"It was reported that on or about December 15, 2012, Licensee failed to keep Resident #1's care plan updated. Resident #1 was placed on a fluid restriction on 7/10/12 and the restriction was lifted on 8/20/12 and Licensee failed to update Resident #1 care plan after the restriction was lifted. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +BH129895,515887,AFH,4/16/2012,"It was reported that on or about April 16, 2016, Licensee failed to provide an adequate medication system resulting in Resident #1 going without a prescribed medication. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +BH149144,515893,AFH,9/17/2014,"On or about October 28, 2014, it was alleged that Reported Perpetrator (RP) failed to administer ordered medication to Reported Victim (RV). According to physician orders and the mediation administration record (MAR) for September 2014, RV was not administered three prescribed medications. A second medication was not administered between 9/12/2014 and 9/18/2014. The licensee failed to administer ordered medication. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO16027,515939,AFH,12/16/2015,"During a renewal inspection, LLA determined that two smoke alarms had been dismantled with battery compartments popped open, one in the upstairs living room and another downstairs in the Licensee's son's bedroom. Mandatory civil penalty issued for failure to have functional smoke alarms. ($250.00 x 2) $500.00 total",3,500,,, +MF105653,515971,AFH,11/9/2010,"On or about November 10, 2010 it was reported that Licensee failed to protect RV from misappropriation of RV's resources. RVs debit card was used to purchase minutes for a phone card that does not belong to RV.",2,0,,,Financial abuse +CO11116,516063,AFH,7/28/2011,,3,0,,, +MS164581,516080,AFH,2/5/2016,"It was reported that on or about February 5, 2016, Licensee failed to protect Resident #1 from physical harm. Licensee found Resident #1 in the living room and took Resident #1 by the arm to guide Resident #1 to his/her room. The following day a large bruise was observed on Resident #1's arm. Wrongdoing on the part of Licensee was substantiated.",2,,Substantiated,Substantiated,Physical Abuse +BH118048,516087,AFH,9/21/2011,"On or about September 21, 2011, it was alleged that Reported Perpetrator (RP) failed to provide adequate service to Reported Victim (RV). It was determined that RP did not follow home health instructions to RV as ordered. The licensee failed to provide appropriate service to RV.",0,0,,, +BH118777A,516087,AFH,12/22/2011,"On or about December 22, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to assess and intervene when Reported Victim #1 (RV1) condition changed. It was determined RV1 had multiple falls in his/her room. The licensee did not develop a care plan that adequately addressed fall prevention as RV1's condition changed. The licensee failed to intervene when RV1's condition changed. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH118777B,516087,AFH,12/22/2011,"On or about December 22, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to seek medical attention in a timely manner for Reported Victim #1 (RV1). It was determined that RV1 was found slumped over RV1's bed and unconscious. RV1's family member contacted 911. The licensee failed to assure timely medical treatment for RV1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH120489B,516087,AFH,7/6/2012,"On or about July 11, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from involuntary seclusion. RV1 lived independently prior to living in the adult foster home (AFH). RV1's significant other lived at the AFH. RV1 would visit h/h significant other Reported Victim #2 (RV2) daily. RV1 sustained a fall and required care. RV1 moved into the AFH. RV1 and RV2 lived in separate bedrooms. RV1 stated that he/she had not seen RV2 in the past seven days because no one at the AFH would assist h/h into h/h wheelchair so RV1 could see RV2. The licensee failed to protect RV1 from involuntary seclusion. The failure is a violation of resident rights and constitutes abuse.",2,,,,Involuntary Seclusion +AL118035,516090,AFH,9/17/2011,"On or about September 17, 2011, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from mental or emotional abuse. It was determined through interviews that RV and RP had an argument regarding the 30 day move out notice. As a result RV felt threatened and emotionally upset by RP's behaviors. RP failed to protect RV from loss of dignity. The failure is a violation of Oregon Administrative Rule.",2,0,,, +AL164785,516098,AFH,9/19/2015,"During the times mentioned in this notice Resident #1 (RV1) was a resident in Licensee_x001A_s Adult Foster Home. RV1 was prescribed a narcotic pain medication to be administered every 8 hours. On 09/19/15, an entire card of RV1_x001A_s medication containing thirty narcotic pain medication tablets was discovered missing from the medication cabinet. During this time it was stated that the key to the medication cabinet had been missing for an unidentified amount of time. RV1_x001A_s last dose of narcotic pain medication was on 9/18/2015. RV1 stated he/she was in a lot of pain and suffered a loss of sleep as a result of not having his/her prescribed pain medication.",3,400,Substantiated,Substantiated,Financial abuse +BO145694,516099,AFH,1/9/2014,"It was reported that on or about January 9, 2014, Licensee failed to provide appropriate care to Resident #1 and failed to provide a safe environment. Reported Perpetrator #2 (RP2) made a comment Resident #1 in good humor and Resident #1 was bothered by the comment as he/she didn't realize RP2 was not being serious. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV105867,516121,AFH,10/25/2010,Resident #2 (RV2) repeatedly offered to have sex with Resident #1 (RV1) who declined to enter into a sexual relationship. Reported Perpetrator (RP1) discussed this behavior with RV2 and asked that RV2 stop approaching RV1. RP1 failed to update the RV2's behavioral care plan. RV1 moved out of the home when RV2 continued to approach him/her.,2,0,,, +MV151512A,516121,AFH,5/7/2015,"On or about May 7, 2015, the Department received a complaint which alleged the facility had failed to administer all medications ordered for Resident #1 (RV1). During the course of the investigation, APS determined that RV1 was not administered all of his/her medications on May 8, 2015. Wrongdoing on the part of the facility was substantiated.",2,,,, +RD129323,516126,AFH,2/20/2012,"Licensee failed to provide appropriate supervision following Resident #1_x001A_s episodes of agitation, exit-seeking and unattended exiting of the home on the evening of February 19, 2012. As a result Resident #1 was able to leave the home a second time at 1:00 AM on February 20, 2012, and was not located for 1.5 hours. Licensee_x001A_s failure placed Resident #1 at risk of serious harm and constituted a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",3,200,,, +BH133060,516142,AFH,4/18/2013,"On or about April 18, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV fell in h/her bedroom on 4/18/13. RV attempted to call for assistance several times. RP did not respond to RV's calls. RV does have a baby monitor located in h/her bedroom, however it was shut off. RV did not sustain any injury from the fall. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO11083,516144,AFH,2/10/2011,"During the operation of her adult foster home, Applicant has repeatedly demonstrated substantial non-compliance with the rules and regulations that are applicable to the health and safety of caring for residents of an adult foster home posing a threat to the health, safety and welfare of residents.",4,0,,, +MS116442A,516144,AFH,3/2/2011,Licensee set up cable service for a resident and added additional services for other individuals in the home.,3,0,,,Financial abuse +MS116442B,516144,AFH,3/2/2011,Licensee told details of an investigation to resident. This action left the resident to believe it was his/her fault the investigation was being conducted causing resident to become upset.,2,0,,,Verbal/Mental abuse +CO11082,516144,AFH,4/1/2010,failed to maintain substantial compliance and failed to maintain financial solvency,0,0,,, +CO12027,516167,AFH,12/30/2011,"During a home visit conducted on December 30, 2011, Licensor discovered Caregiver #1 had been administering injections to Resident #1 without the appropriate delegation. Resident #1_x001A_s Medication Administration Records (MAR) reflected Caregiver #1 had administered injections to Resident #1 from December 5, 2011, until December 31, 2011. Caregiver #1 was not delegated to administer the injections until December 31, 2011. Licensee's failures are a violation of Oregon Administarative rules. Wrongdoing on the part of the Licensee has been substantiated.",2,150,,, +HB116923A,516198,AFH,5/6/2011,"On or about May 6, 2011 it was reported that RP2 has been routinely been charging both RV1 and RV2 for personal wipes. W3 writes two checks per month on RV2's behalf for personal spending; both checks are written in RP2's name. One check is for $50.00 for incidental items that RV2 needs for daily living. RP2 is supposed to purchase essential items on RV2's behalf. No accounting of this $50.00 monthly check was discovered throughout the course of the this investigation.",2,0,,,Financial abuse +HB116923B,516198,AFH,5/6/2011,"During an investigation on May 6, 2011, a concern regarding verbal mistreatment was discovered. RP2 has used foul language in the AFH, including the use of the ""F word"" on multiple occasions that has promoted a non-homelike environment.",2,0,,, +HB116721,516198,AFH,4/11/2011,"There was a concern that the Licensee failed to provide a safe environment. RV was covered in his/her own feces mid morning of April 12, 2011.",2,0,,, +MS132197B,516210,AFH,1/23/2013,"It was reported that on or about January 23, 2013, Licensee failed to provide appropriate care for Resident #2. Licensee has forced Resident #2 to eat when it was apparent that Resident #2 does not want the food. Licensee used a large spoon to feed Resident #2, Resident #2 would cough and choke throughout the meal when Licensee would give Resident #2 large bites. Licensee would rush Resident #2 to eat, and failed to care plan around the care Resident #2 requires while eating. Licensee's failures are a violation of Oregon Administrative Rules and is considered physical abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Physical Abuse +MS132197C,516210,AFH,1/23/2013,"It was reported that on or about January 23, 2013, Licensee failed to assure resident rights. Resident #1 had requested to call 911 to go to the hospital. Licensee refused to allow Resident #1 to call 911. Licensee unplugged the phone and gave the phone Resident #1. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS132197D,516210,AFH,1/23/2013,"It was reported that on or about January 23, 2013, Licensee failed to provide appropriate care to Resident #1 by failing to administer Resident #1's medication as ordered. Resident #1 had a doctors order to receive a medication three times daily. Licensee did not administer the medication as ordered three times daily. Licensee did initial Resident #1's medication administration record as though he/she was administering the medication when in fact he/she was not administering the medication. Licensee's failures are a violation of Oregon Administrative Rules, are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +MS132197E,516210,AFH,1/23/2013,"It was reported that on or about January 23, 2013, Licensee failed to protect Resident #2 from inappropriate sexual contact. Resident #2 was unable to communicate his/her wishes and needs due to his/her diagnoses. Licensee would sit on Resident #2's lap and would kiss Resident #2. Resident #2 would lean away when Licensee would sit on his/her lap. Licensee's failures are a violation of Oregon Administrative Rules and is considered sexual abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Sexual abuse +HB120273,516255,AFH,3/18/2012,"On or about March 18, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV fell to the floor out of h/h bed. RP notified RV's primary care physician. RP did not get a response back from RV's primary care physician (PC). RV began to complain of pain on 3/22/12. On 3/22/12 RP notified RV's PCP of RV's pain and swelling on the area where RV fell. RP requested that RV be x-rayed. RV complained of more pain between 3/24/12 and 3/28/12. RV was not x-rayed until 3/29/12. RV's x-ray showed that RV sustained a hip fracture. The licensee failed to provide a safe environment for RV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH116703,516258,AFH,4/5/2011,"On or about April 5, 2011, it was alleged Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim #1 (RV1). It was determined that RP1 has speech and cognitive impairment and had a history of exit seeking from the Adult Foster Home (AFH). RP1 shut off the door alarm and did not monitor RV1. RP1 Failed to provide a safe environment for RV1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES117756,516265,AFH,8/15/2011,"It was reported that on or about the evening of August 15, 2011, a fire occurred at the licensee's adult foster home. The investigation revealed several fire/safety violations that placed Resident #1 in risk of serious harm. Licensee failure to provide a safe environment was substantiated.",3,750,,, +CO11119,516280,AFH,10/25/2011,"*** INTERNAL ONLY *** Left three residents alone without a cg; med cabinet was unlocked and accessible to residents (pictures of the unlocked med cabinet were taken by Benton County Sheriff's Deputy). One resident interviewed stated provider regularly leaves them alone without assistance available and that Licensee often locks his mother in her room. Sheriff was notified. Condition restricting admissions was issued on October 28, 2011.",3,0,,,Neglect +AL128820,516280,AFH,10/25/2011,"Licensee left residents alone in the adult foster home with no approved qualified caregiver on duty to meet resient needs. Licensee locked Resident #2 in his/her room during this time, an individual who is cognitively impaired and requires full assistance in an emergency.",3,0,,,Neglect +CO11028,516397,AFH,1/10/2011,Provider failed to obtain an approved criminal history check,4,0,,, +CO11029,516397,AFH,1/10/2011,Provider failed to obtain an approved criminal history check,4,0,,, +MV150257,516458,AFH,2/12/2015,"It was reported that on or about February 23, 2015, Licensee failed to follow Resident #1's physician orders. Wrongdoing on the part of the Licensensee was substantiated.",2,,,, +CO15154,516458,AFH,7/30/2015,The facility failed to assure a qualified caregiver was present. Mandatory civil penalty sanction.,3,250,,, +CO11143,516460,AFH,10/13/2011,"A monitoring visit was conducted at the Licensee_x001A_s Adult Foster Home (AFH) on October 13, 2011. During the visit the licensor discovered that caregiver #1 and caregiver #2 were providing care with no other qualified caregiver on duty. Caregiver #1 and #2 were providing care in the AFH without having an approved criminal records check. The licensee_x001A_s failure to ensure a safe environment is a violation of the Oregon Administrative Rules (OARs).",3,150,,, +MV121017,516460,AFH,8/30/2012,"On or about August 30, 2012, Reported Perpetrator #2 (RP2) had an argument with Reported Perpetrator #3 (RP3) at the licensee_x001A_s Adult Foster Home (AFH). RP2 left the AFH and contacted law enforcement leaving only RP3 in charge of all residents. According to the police report, RP3 was intoxicated and was in possession of fire arms. RP3 was taken into custody and arrested. Resident #1 (RV1) and Resident #2 (RV2) care needs require that two qualified caregivers be on duty 24 hours a day. RV1, RV2, Resident #3 (RV3), and Resident #4 (RV4) were left alone without a qualified caregiver for at least 2 hours. + + + +On September 10, 2012, it was observed by the Adult Protective Service investigator that Witness #2 (W2) was the only qualified caregiver present in the AFH. W2 contacted RP2 upon the investigators arrival. RP2 arrived back at the AFH within fifteen minutes. UPDATE 6/18/13: FOD sent this date. Emailed AR to request to begin the aging process this date.",3,450,,,Neglect +CO15170,516487,AFH,8/20/2015,Facility failed to properly store Resident Medication.,3,200,,, +MV134112,516557,AFH,8/14/2013,"It was reported that on or about August 14, 2013, Licensee failed to proper care to Resident #1 (RV1) by failing to administer RV1's medication as ordered. Licensee stated that RV1 did run out of medication on August 10, 2013, and was not administered the medication until August 15, 2013. Licensee failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV146018,516557,AFH,2/5/2014,"It was reported that on or about February 5, 2014, Licensee failed to provide a safe medication administration system. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MS134129,516581,AFH,6/14/2013,"On or about June 14, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from rough treatment. RV's behavioral careplan notes that caregivers are to speak calmly with RV and soothe RV's nerves, reassure RV's fears or reason for agitation and speak gently. RV and Reported Perpetrator #2 (RP2) have had ongoing issues. RV and RP2 have never ""clicked"". RP2 was transferring RV, RV took RV's hands off of RV's walker and became comabtive toward RP2, RP2 grabbed RV and held RV's arms down. After RV was transferred to his/her bed RP2 attempted to get RV's dentures out. RV continued to be combative and RP2 pushed RV's arms down multiple times. As a result RV sustained bruising to his/her arm.",2,,Not Substantiated,Substantiated,Physical Abuse +MS116386A,516584,AFH,8/1/2010,"On or about February 17, 2011, it was reported that Licensee failed to protect Resident #1 (RV1) from financial exploitation. Interviews and Observations concluded that wrongdoing on the part of the Licensee was substantiateed.",3,400,,,Financial abuse +MS116386B,516584,AFH,8/1/2010,"On or about February 17, 2011, it was reported that the Licensee failed to provide a safe medication administration system. Interviews and Observations concluded that wrongdoing on the part of the Licensee was substantiated.",3,0,,, +MF129416A,516584,AFH,3/5/2012,"On or about March 5, 2012, Caregiver 1 transferred Resident 1 using a hoyer lift. Caregiver 1 left Resident 1 hanging in the hoyer lift without clothing for more than an hour. Caregiver 1 failed to respond to Resident 1's repeated requests to be removed from the hoyer. Licensee failed to protect Resident 1 from neglect.",3,0,Substantiated,Substantiated,Neglect +MF129552,516584,AFH,3/20/2012,"Resident #1_x001A_s 60mg narcotic medication was refilled on March 6, 2012. The prescription refill contained 45 tablets. Physician orders stated one tablet of the medication was to be administered to Resident #1 every 8 hours. On or about March 18, 2012, it was discovered there were no tablets remaining revealing approximately 12 tablets of Resident #1_x001A_s narcotic medication were missing. Licensee failed to have a safe medication administration system to protect residents from theft of medications.",3,0,,,Financial abuse +CO12061,516584,AFH,6/28/2012,"On June 21, 2012, the Department received information that a former resident of Licensee's AFH had head lice. It was determined that on May 3, 2012, the CRN documented that Resident #1 had head lice while residing at Licensee's AFH. The Licensee failed to contact resident's medical professional. Licensee began an over-the-counter treatment without a physician's order. When Resident #1 moved to another AFH and had his/her head shampooed, the infestation was identified when bugs were found in the towel being used to dry his/her hair.",2,0,,,Neglect +MS120373,516584,AFH,6/26/2012,"Resident #1's (RV) progress notes indicate that on or about May 2, 2012, Resident #1 was observed scratching his/her hair. Lice were found in RV1's hair the following day. Reported Perpetrator #1 (RP1) procured an over-the-counter shampoo treatment for head lice instead of contacting RV1's medical professional. Facility failed to obtain a written order for treatment of lice. The failure is a violation of Oregon Administrative Rule.",2,0,,, +MS121748,516584,AFH,11/16/2012,"A complaint was received that alleged the Licensee had failed to provide appropriate care and services to Resident #1. Resident #1 had a hand contracture that made him/her susceptible to developing skin issues. Resident #1 was observed multiple times without a rolled cloth in his/her hand to limit the possibility of skin damage. On or about November 16, 2012, a medical professional noted that the skin on Resident #1's hand was peeling and an odor present. Resident #1's care plan was reviewed. The care plan had not been updated to reflect Resident #1's current hand care needs. The investigation concluded that Licensee failed to provide appropriate care and services. The failure is a violation of Oregon Administrative Rule.",2,0,,, +MV149085,516586,AFH,10/29/2014,"On or about October 30, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide appropriate care to Reported Victim (RV). During a physician visit on 10/4/2014 RV was diagnosed with migraines. RV was prescribed medication #1 up to four tablets per day to prevent migraines. RP2 acknowledged overlooking the instructions for medication #1 and was administering one tablet per day. RV experienced multiple migraines between 10/4/2014 and 10/30/2014. RV ran out of medication #2 to help with immediate migraine relief on or about 10/17/2014. Witness #1 (W1) stated that he/she informed RP2 that RV had ran out of medication #2. The licensee failed to provide appropriate care to RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +CO15189,516586,AFH,9/3/2015,RM John Frisinga working in the AFH without a currently approved background check. Another caregiver was also in the home (not mandatory).,3,200,,, +NB145609,516601,AFH,1/7/2014,"On or about January 7, 2014, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RV and RP were involved in a relationship for several years. RV stated that when RP drinks he/she becomes aggressive. RV stated that RP had pushed RV on multiple occasions. RV stated that he/she decided to leave the facility due to RP's behavior. On one occasion RP threatened to physically harm RV and RV's pet. Law enforcement was contacted but no arrest was made. The licensee failed to protect RV from inappropriate verbal comments. The failure is a violtion of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +CO14003,516637,AFH,12/30/2013,"A licensing visit conducted on December 30, 2013 discovered Licensee had left her spouse alone and in charge of the residents. Licensee's spouse did not have an approved background check as a caregiver, current CPR and First Aid, orientation or a completed caregiver workbook. This failure is a violation of Oregon Administrative Rule. UPDATE: FOP sent on 7/30/14.",3,250,,, +CO14133,516637,AFH,7/9/2014,Licensee had an unqualified cargiver workin unsupervised in her Adult Foster Home. FOP sent,2,250,,, +GP147694,516637,AFH,7/10/2014,"It was reported that on or about July 10, 2014, Licensee failed to provide a safe medication administration system for Resident #1 (RV1). RV1 had physicians orders to receive 10 mg of a specific medication nightly. Lic3ensee was administering 15 mg to RV1 nightly. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO15241,516637,AFH,12/2/2105,Voluntarily reduced capacity - Condition not needed,4,,,, +NB153484B,516642,AFH,11/7/2015,"The Department received a report that the facility failed to maintain an adequate medication system, and was overmedicating RV. RV had resided at the facility for about two months when his/her health began to decline. RV was in pain and his/her Primary Care Provider (PCP) prescribed a narcotic pain medication. RV's family did not want the facility to administer this medication The facility followed PCP orders and administered doses of the narcotic, but facility Medication Administration Records (MAR) did not clearly indicate dosages dispensed for narcotic or PRN medications. Facility records also indicate the facility did not follow doctor orders when dispensing prescribed medication, and dispensed medications without doctor's orders. The PCP discontinued the narcotic medication, and the facility disposed of the narcotics before receiving the doctor's order discontinuing the narcotic. RV's health continued to decline and RV had difficulty eating and hydrating. RV was transferred to the hospital for care. RV has since died.",2,,,, +CO11093,516688,AFH,4/21/2011,"A monitoring visit was conducted at Licensee_x001A_s Adult Foster Home (AFH) on April 21, 2011. The Licensor discovered that the Licensee admitted Resident #1 into his/her AFH on April 10, 2011 who was a full assist in more than three Activities of Daily Living (ADLs). The Licensee_x001A_s AFH is licensed as a Class 2 home. A Class 2 AFH Licensee may not admit residents that require full assistance in more than three ADLs. The Licensee_x001A_s exception request to care for Resident #1 wasn_x001A_t received by the Local Office until May 17, 2011.",2,500,,, +HB117418,516702,AFH,7/11/2011,,3,0,,,Neglect +CO11146,516702,AFH,8/5/2011,"An inspection was conducted at Licensee_x001A_s Adult Foster Home (AFH) on August 5, 2011. Licensor observed that the smoke alarm in the hallway by the kitchen had been removed and not replaced. Licensee_x001A_s failure to ensure a safe environment is a violation of Oregon Administrative Rules (OARs).",3,250,,, +HB117418A,516702,AFH,7/11/2011,"On or about July 12, 2011, it was reported that Resident #1 (RV1) did not receive proper care when Reported Perpetrator #3 (RP3) became ill. It had been determined through interviews that RV1 experienced pain and anxiety. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +HB117418B,516702,AFH,7/11/2011,"It was reported that on or about May 19, 2011, the Licensee had failed to provide a safe environment for Resident #1 (RV1). RV1_x001A_s Care Plan indicated that RV1 was a fall risk. Reported Perpetrator #3 (RP3) did not finish RP3_x001A_s shift and left the facility without a qualified caregiver being present. RV1 experienced a fall that day while RV1 was left unattended. The investigation concluded that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES120103,516722,AFH,5/21/2012,"On or about May 21, 2012, it was reported that Licensee failed to protect Resident #1 (RV1) from risk of serious harm by Resident #2 (RV2). Around the first week of May 2012 there was an undocumented shoving incident between RV1 and RV2 where RV1 was shoved by RV2. Licensee's failures are a violation of resident rights. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Physical Abuse +ES132216B,516722,AFH,12/15/2012,"It was reported that on or about December 15, 2012, Licensee failed to provide appropriate care to Resident #1. Resident #1 experienced an unplanned need for night time assistance around 1:00 AM ON January 16, 2012. Resident #1 did not get assistance until 7:00 AM and at that time refused care by Reported perpetrator #2 (RP2). Resident #1 was care planned as needing night time care. Licensee failed to follow Resident #1's care plan. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +ES132216A,516722,AFH,12/15/2012,"It was reported that on or about December 15, 2012, Licensee failed to maintain an safe medication administration system. Reported perpetrator #2 (RP2) was dispensing medication on the morning of January 16, 2013. RP2 had placed Resident #1's medication in front of Resident #2 and Resident #2's medication in front of Resident #1. In the absence of RP2 Resident #1 took Resident #2's medications and ingested them. Resident #2 noticed that the medication placed in front of him/her did not belong to Resident #2. Resident #1 was placed on 24 hour monitoring do to risks associated with ingesting the wrong medications. As a result of ingesting the medication Resident #1 could not participate in a medical treatment e/she was scheduled to attend on the day in question. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB151309A,516723,AFH,5/18/2015,"It was reported that on or about May 18, 2015, Licensee failed to protect Resident #1 (RV1) emotional/verbal abuse. Reported Perpetrator #2 (RP2) was short with RV1 and spoke to RV1 in a ""mean"" and ""scalding"" tone, saying ""don't spit"". Wrong doing on the part of the Licensee was substantiated. Licensee's failure to protect resident rights is a violation of Adult Foster Home Oregon Administrative Rules, an is not considered abuse.",2,,,, +MS104507,516744,AFH,6/9/2010,Reported Perpetrator #1 and #2 argued in loud voices that made some of the residents uncomfortable. RP1 and 2 failed to provide a home-like environment.,2,0,,, +MS147165,516744,AFH,5/22/2014,"On or about May 22, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV's progress notes dated March 20, 2014, April 9th, 2014, April 24th, 2014, and May 15th, 2014, note that RV is a two person transfer and RV requires requires two people to assist RV in the shower and when RV gets in and out of a chair. RV's care plan from the previous facility indicates that RV is a ""two person transfer when ambulating, to shower, getting out from couch."" RP acknowledged that he/she has a hard time getting RV up and that RV is too much for RP to care for. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS147141,516744,AFH,5/20/2014,"On or about May 21, 2014, it was alleged that Reported Perpetrator (RP) failed to assure resident rights for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). RV1 continues to verbally harass RV2. RV1 opens the bathroom door and peaks in on RV2 and says ""you are shitting aren't you?"" While t the dinner table with other residents, RV1 will tell RV2 that RV2 ""shits everywhere"" RV2 verbally expressed that he/she does not like this and that it is embarrassing for RV2. Care plan for RV1 dated 5/2/2014 notes that RV1 gets rude and calls other residents names and RV1 constantly needs to be reminded to not bother the other residents. No other interventions are listed on the 5/2/2014 care plan for RV1.",2,,,, +MS147425B,516744,AFH,6/17/2014,"On or about June 17, 2014, Adult Protective Services (APS) received a complaint that the facility failed to provide a safe environment. During the course of the investigation, APS determined that when RV1 was using the bathroom, RV2 would enter the bathroom and make inappropriate or insulting comments to RV1 or call RV1 names. RV2 also called RV1 names at other times/places. Facility progress notes from May through June 2014 verify that this behavior occurred and facility was aware of it. RV2's behaviors and calling RV1 names made RV1 sad and feel like moving out. The local licensing authority directed facility to put a lock on the bathroom door which the facility refused to do. After this time period, the facility applied for an exception to bring in additional staff to assist with RV2. Facility made a referral to a behavioral coach to work with RV2. Facility put a curtain around the toilet area for privacy, a radio on the bathroom counter so that RV1 does not hear RV2 calling RV1 names, and blocked the bathroom door entrance from RV2's bedroom. For the time period that facility failed to stop RV2 from insulting RV1, calling RV1 names, or making derogatory comments about RV1, the facility failed to protect RV1 from verbal abuse. Facility's failure is a violation of resident's rights, constitutes neglect, and is considered abuse.",3,400,,,Neglect +NB117898,516753,AFH,9/3/2011,"On or about September 6, 2011, it was reported that the Licensee failed to provide a safe medication administration system. On September 3, 2011, Resident #1 (RV1) consumed Resident #2's medications that were left sitting on a file cabinet after the 5:00 PM medication pass. As a result of consuming RV2's medications, RV1 was transported to the hospital. It was found that wrongdoing on the part of the Licensee was substantiated.",0,0,,, +NB118285,516753,AFH,10/20/2011,"It was reported that on or about October 13, 2011, the Licensee failed to provide a safe medication administration system for Resident #1 (RV1). RV1's medications were not being administered s ordered. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MF117925,516758,AFH,9/8/2011,"It was reported on or about September 8, 2011, Licensee failed to administer medications to Resident #1 (RV1) and Resident #2 (RV2) as prescribed. Licensee failed to provide a safe medication administration system. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS118322A,516758,AFH,10/28/2011,"On or about October 28, 2011, it was reported that the Licensee failed to protect Resident #1 (RV1) from loss of personal property. When RV1 was admitted to Licensee's Adult Foster Home (AFH) RV1 had a diamond ring, and after being moved from the AFH RV1's ring was missing. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +MS118322B,516758,AFH,10/28/2011,"It was reported on or about October 28, 2011, that the Licensee failed to protect Resident #1 (RV1) from financial exploitation. Licensee admitted to taking money from RV1 for over a 3 year time period. Wrongdoing on the part of the Licensee was substantiated.",3,0,,,Financial abuse +HB132718B,516774,AFH,3/16/2013,"It was reported that on or about March 16, 2013, Licensee failed to provide adequate services to Resident #1 (RV1). On March 16, 2013, an altercation took place at the Adult Foster Home (AFH) between Licensee and RV1's spouse. Police were called and defused the situation between the Licensee and RV1's spouse. On March 23, 2013, Licensee issued RV1 a notice of involuntary move based on not being able to meet RV1's care needs as a result of his/her spouses behavior. On March 24, 2013, Licensee called an ambulance and sent RV1 to the hospital. RV1 arrived at the hospital with no medical reason for hospitalization except for a safety risk placement in a new facility. RV1 did not want to be in the hospital and did not know why he/she was sent to the hospital. Licensee was able to meet RV1's care needs but could not deal with his/her spouses behavior. Licensee denied RV1 re-admittance when it was found he/she did not require hospitalization. Licensee did not give RV1 the appropriate move out notice and chose to send RV1 to the hospital. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +BH117651B,516783,AFH,8/5/2011,"On or about August 8, 2011, it was alleged that Reported Perpetrator (RP) failed to provide adequate care and services to Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), and Reported Victim #5 (RV5). It was determined that nighttime care was not provided to RV1, and appropriate care was not provided to RV3 after a change in condition. Licensee failed to provide needed services to RV's. Licensee's failure constituted abuse.",0,0,,,Neglect +BH117651C,516783,AFH,8/5/2011,"On or about August 8, 2011, it was alleged that Reported Perpetrator (RP) confined Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), and Reported Victim #5 (RV5) to their rooms. It was determined that RV1 was put to bed at approximately 7pm and was expected to stay in bed until approximately 7-8:30am. Licensee failed to protect RV1 from involuntary seclusion. RV1 did not sustain a negative outcome.",0,0,,, +ES134846,516810,AFH,10/14/2013,"RV came to home of RP from AFH of primary provider for respite care, and was with RP for six days. During the respite stay RP did not give RV three medications which were on the MAR. The MAR was determined to be confusing; however, RP did not attempt to clarify the MAR by calling the primary provider or physician. No harm to the resident was identified.",1,,,, +HB150442,516832,AFH,3/3/2015,"It was reported that on or about March 3, 2015, Licensee failed to protect Resident #1 from inappropriate verbal comments. Licensee was heard calling Resident #1 an inappropriate name. Licensee's failures are a violation of Oregon Administrative Rules, and is considered verbal abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Verbal/Mental abuse +CO14037,516846,AFH,8/8/2013,Licensee allowed two caregivers without approved background checks to provide care. Caregivers were left alone with residents.,3,500,,, +RD145567,516846,AFH,12/31/2013,"On or about December 31, 2013, Resident #1's medical professional increased his/her dosage of a narcotic pain medication. Upon returning from the medical appointment, Resident #1 reported the dosage increase to the licensee. The licensee did not agree with the dosage increase. During the subsequent conversation between Resident #1 and the licensee, the licensee yelled at Resident #1. Facility failed to protect Resident #1 from inappropriate verbal communication and failed to treat Resident #1 with dignity and respect. These failures are violations of Oregon Administrative Rule.",2,,,, +RD145869A,516846,AFH,1/10/2014,"On September 25, 2013, Resident #1 was prescribed a topical pain medication. On September 27, 2013, Resident #1's pharmacy delivered a total of 8 bottles, totaling 840 grams. A review of Resident #1's Medication Administration Records documented that Resident #1 was administered approximately 125 grams between September 28 and November 17, 2014. Resident #1 stopped using the medication because he/she felt it was not effective. On January 13, 2014, three bottles were observed in a locked medication cabinet at licensee's adult foster home. Based on Resident #1's usage, there were approximately four bottles unaccounted for. The theft of Resident #1's medication is considered financial exploitation and constitutes abuse. The investigation failed to determine the party or parties responsible for the missing medication. Therefore, the finding of abuse was apportioned to an unknown individual(s). Licensee failed to exercise reasonable precautions against any condition(s) that could threaten the health, safety or welfare of Resident #1. The failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Financial abuse +RD145869B,516846,AFH,1/10/2014,"Resident #2 (RV2) had a written order for a calcium citrate supplement. RV2 ran out of his/her supplement at the beginning of January 2014. Resident #1 (RV1) previously took a chewable form of calcium carbonate. Licensee took RV1's remaining bubble pack of calcium carbonate and wrote RV2's name on it. RV2's Medication Administration Record (MAR) for January 2014 reflects that RV2 was not dispensed either calcium citrate or calcium carbonate in January 2014. On January 31, 2014, RV2 was provided with his/her calcium citrate. Licensee failed to have RV2's medication available and failed to administer the ordered medication. These failures are violations of Oregon Administrative Rule.",2,,,, +CO14064,516846,AFH,3/20/2014,Revocation #AFHRV14-008; issued 07/14/14,3,,,,Neglect +CO14066,516846,AFH,3/28/2014,See # AFHRV14-008; issued on 07/14/14 instead,2,,,, +RD146193,516846,AFH,2/24/2014,"Resident #1's care plan indicated that Resident #1 has a history of arguing with staff and entering personal areas. The care plan addressed that caregivers should have a calm and friendly manner when reminding Resident #1 to respect other individual's personal areas. On or about February 24, 2014, Resident #1 walked through a caregiver's room in order to get to a storage area. The licensee yelled and spoke to Resident #1 in a disrepectful manner which was contradictory to the interventions included in the resident's care plan. The investigation concluded that wrongdoing on the part of the licensee was substantiated.",2,,,, +RD146681,516846,AFH,3/16/2014,"On July 8, 2013, Resident #1 was prescribed 5,000 IU of Vitamin D to be given every day. On or about January 28, 2014, Resident #1 had a new order to take 50,000 IU of Vitamin D twice a week. During the course of the investigation it was discovered that the facility was giving 1,000 IU of Vitamin D every day without a physician's order, instead of the 50,000 IU that was ordered. It was further identified that the facility mixed the remaining 1,000 IU Vitamin D gel capsules with the 50,000 IU capsules in the same bottle. Witness #1 (W1) could not remember which colored capsule was given to the resident. Licensee (RP1) stated she had been administering 1,000 IU capsules. Medication Administration Records for Resident #1 indicate that Resident #1 was dispensed 50,000 IU of Vitamin D every day between January 31, 2014 through March 16, 2014. Licensee failed to maintain a safe medication administration system. Licensee's failure is a violation of Oregon Administrative Rule.",2,,,, +RD146724,516846,AFH,3/20/2014,"Resident #1 had a history of wandering away from the adult foster home (AFH) and needed cueing for most activities of daily living. Resident #1_x001A_s care plan indicated that an alarm should be placed on the door and that the caregiver should redirect Resident #1 back into the house in the event that he/she eloped. On or about March 20, 2014, Resident #1 wandered away from the AFH unnoticed and was found two blocks away from the AFH. Licensee reported that he/she had placed an alarm on the front door but acknowledged that the alarm was not in place at the time Resident #1 eloped. Licensee failed to follow Resident #1_x001A_s care plan which placed Resident #1 at potential risk of serious harm. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,450,,,Neglect +CO14129,516846,AFH,6/26/2014,Unqualified caregiver was left alone with residents.,3,250,,, +BO147731,516846,AFH,7/3/2014,"On or about July 7, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV was moved to a new facility on July 3, 2014. When RV arrived to the new facility RV's finger nails were not and were dirty. RV's hair was not clean and was matted down. RV's clothes had a strong odor and BM on the undergarments. It was observed RV's bottled medications dated April 2014, May 2014, and June 2014 were all still in the original bottle indicating that RV did not receive his/her medications as required. RV's medication administration record dated April 2014, May 2014, and June 2014 were initialed as all medication being administered. The licensee failed to provide appropriate care and services. The failure is a violation of resident rights and constitutes abuse.",3,,,,Neglect +CO13048,516859,AFH,12/13/2011,"On December 13, 2011, Licensee failed to have a functioning smoke alarm in a residents room (room 3). On November 20, 2012, Licensee failed to have a functioning smoke alarm in his/her daughters room. Licencee's failures are a violation of Oregon Administrative Rule. Wrongdoing on the part of the Licensee was substantiated.",2,500,,, +AL117254A,516867,AFH,1/8/2011,"On or about January 10, 2011 it was reported that RV was transported to the hospital with noted bruising over many parts of this/her body. RV falls while attempting to transfer him/herself and sometimes while being assisted as a one-person transfer, RV will fold at the knees and fall. RP did not have an updated Care Plan for the RV.",2,0,,, +AL118502,516867,AFH,7/20/2011,"It was alleged that on or about July 20, 2011, Licensee failed to assure timely medical treatment for Resident #1 (RV1). On July 20, 2011, RV1 fell due to dizziness and requested to go to the hospital for treatment. Licensee did not comply with RV1's request to go to the hospital. On July 21, 2011 family members of RV1 transported him/her to the hospital for an evaluation. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +AL129166,516867,AFH,10/24/2011,"It was reported that on or about October 24, 2011, Licensee failed to report potential or suspected abuse. On the morning of October 25, 2011, Resident #1 (RV1) was found to have a black eye. Upon questioning, RV1 and Resident #2 (RV2) stated that they got into a fist fight over the volume of RV1's television. Based on physical evidence and the resident's statements the Licensee determined that RV1 and RV2 got into a physical altercation with one another. Licensee failed to report suspected abuse as required by Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +AL120872A,516867,AFH,8/8/2012,"It was reported that on or about August 8, 2012, Licensee failed to assure Resident #1 (RV1) was safe. On August 8, 2012, Licensee placed RV1's and Resident #2's (RV2) medications in medication cups and set them on the dinning table unattended. RV1 mistakenly took and ingested RV2's medications instead of his/her own. Approximately an hour later RV1 was found unresponsive and transferred to the hospital. Licensee's failures are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",3,400,,,Neglect +AL120872B,516867,AFH,8/8/2012,"It was reported that on or about August 8, 2012, Licensee failed to provide Resident #1 (RV1) with appropriate skin care. On August 8, 2012, RV1 was transfered to the hospital. Upon arrival to the emergency department, RV1 smelled of a foul odor, had several level 2 pressure ulcers to his/her peri-rectal area, perineal irritation, unkept nails, scaly skin with a wart-like growths, and an open sore with some scabbing on his/her chest. Licensee's failures are a violation of Oregon Administrative Rules, is considered neglect and constitutes abuse.",2,0,,,Neglect +AL132075,516867,AFH,8/16/2012,"It was reported that on or about August 16, 2012, Licensee failed to provide a safe medication administration system for Resident #1. On August 1, 2012 Resident #1's narcotic medication was refilled with a total of 90 tablets. Resident #1 was to receive 3 tablets a day. On August 16, 2012 Resident #1 moved from Licensee's Adult Foster home. Before leaving Licensee's Adult Foster Home, Licensee gave Resident #1 a bag of his/her remaining medications. When Resident #1 arrived at the new facility on August 16, 2012 Resident #1 only had 4 narcotic pain tablets remaining. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +MM148712,516878,AFH,9/22/2014,"It was reported that on or about September 22, 2014, Licensee failed to protect Resident #1 (RV1) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) told RV1 he/she was acting like a baby when he/she was found crying about a death in his/her family. Licensee's failures are a violation of adult foster home Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MM132058,516879,AFH,1/2/2013,"It was reportred that on or about January 2, 2013, Licensee failed to Protect Resident #1 from financial exploitation. Reported perpetrator #2 (RP2) took aproximately $200 from Resident #1's bedroom. After an investigation was started RP2 admitted to taking the money and returned the money to Resident #1. Licensee's failures are a violation of Oregon Administrative Rules (OARs). RP2's actions are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",3,0,Not Substantiated,Substantiated,Financial abuse +CO11066,516888,AFH,3/29/2011,,4,0,,,Neglect +MV116952A,516888,AFH,5/10/2011,"On or about May 10, 2011 it was reported that RP was not providing proper care for RV and that RP removes RV's call button at night, resulting in RV being soaked in urine in the morning. Although RV and RP deny that RV's call button is removed at night so that RV cannot call for help to use the toilet, there is written documentation and three witnesses that state that these things have occurred.",2,0,,, +MV116952B,516888,AFH,5/10/2011,"On or about May 10, 2011 it was reported the Licensee was mismanaging medications. Copies of the MARs for all residents show medications given appropriately. Narcotic sheets for RV2 and RV3 do not match counts. One of RV3's medications has 5 missing pills, another medication has 2 missing pills. One of RV2's medications had 1 extra pill. There was a missing bubble pack of medication for RV2 and a missing NARC sheet for one of RV3's medications. RV2's sheet was with RV3's medications.",2,0,,, +MV118327,516921,AFH,10/27/2011,"On or about October 27, 2011, it was alleged that Reported Perpetrator (RP) failed to properly secure medication for Reported Victim (RV). It was determined that RP placed medications in cups and placed the cups where they were easily accessible to residents. Licensee failed to properly secure medications.",2,0,,, +CO15078,516947,AFH,4/1/2015,"Licensee was out of the country for 2 weeks. While licensee was out of the country, a resident fell. The incident report was completed while licensee was still out of the country by licensee's spouse and signed by both spouse and licensee. Licensee admitted she did not sign the report.",2,750,,, +CO15258,516951,AFH,12/22/2015,Licensee failed to conduct timely evacuation drills. This is the 3rd time and the 2nd CP to be issued on this matter.,3,250,,, +CO15022,516987,AFH,1/13/2015,"Licensee had unqualified caregiver Dana Davidson working alone in her AFH on January 8, 9, and 10 of 2015. Additionally, Licensee had 6 caregiveres working in her home without having completed the required caregiver orientation to the home. Licensee's failures are a violation or AFH OARs.",3,250,,, +ES117118,517032,AFH,5/17/2011,"On or about May 17, 2011, it was alleged that Reported Perpetrator #2 (RP2) failed to protect Reported Victim (RV) from loss of medication. It was determined that medication was stolen from RV, and RV suffered minor harm. The licensee failed to protect RV from financial exploitation.",2,0,,,Financial abuse +ES117197,517032,AFH,6/10/2011,"On or about June 10, 2011, it was discovered that caregiver #2 took and consumed a prescribed medication that belonged to resident #1. Licensee_x001A_s failure to protect resident #1 from loss of medication is a violation of resident rights, is considered financial exploitation.",3,0,,,Financial abuse +ES117215,517032,AFH,6/10/2011,"Adult Protective Service investigator conducted a visit at the licensee_x001A_s Adult Foster Home on June 10, 2011. During the visit the APS worker conducted an audit of some of Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3) and Reported Victim #4 (RV4) medications. The APS worker did a hand count of several medications for RV1, RV2, RV3 and RV4 and discovered that the Reported Perpetrator (RP) was not dispensing all of the medications that are prescribed to the residents. The APS worker also discovered that RP combined old bottles of medication with new bottles of medication. The licensee_x001A_s failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.",3,200,,, +ES146706,517041,AFH,4/10/2014,"On or about April 10, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV was admitted to the facility on 1/29/2014. The screening and assessment for RV was not completed until 2/1/2014. The licensee failed to conduct an appropriate screening and assessment prior to admitting RV as required. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB150914A,517059,AFH,4/13/2015,"It was reported that on or about April 13, 2015, Licensee used Resident #1;s sleep aid medication as a chemical retrain on Resident #1. Licensee had been administering Resident #1's sleep medication during daytime hours. Licensee's failures are a violation or Oregon Administrative Rules, and is considered neglect and constitutes abuse.",3,200,,,Neglect +HB150914B,517059,AFH,4/13/2015,"It was reported that on or about April 13, 2015, Licensee failed to provide appropriate care to Resident #1. Licensee failed to seek timely medical attention for Resident #1 when his/her condition changed. Licensee's failure is a violation of Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee has been substantiated.",3,,,,Neglect +CO13149,517120,AFH,12/16/2013,"On December 16, 2013, the licensor conducted visit at the licensee_x001A_s adult foster home (AFH) in response to a complaint. Upon arrival caregiver (TW) was the only caregiver on duty. Further inspection concluded that TW did not have a current criminal background check. TW_x001A_s criminal background expired on 11/5/2013. The licensee failed to have a qualified caregiver on duty as required. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +CO14016,517120,AFH,1/17/2014,"The Licensee has demonstrated substantial non-compliance with the rules and regulations that are applicable to the health and safety of caring for residents of an adult foster home. The Licensee_x001A_s failures have resulted in potential for serious harm to residents. These failures demonstrate the Licensee failed to exercise reasonable precautions to protect residents from any threat of harm to their health, safety or well-being. Settlement agreement entered in May, 2014. Withdrawal of Revocation and Condition. Sent 12/23/2014.",3,0,,, +CO14015,517120,AFH,1/17/2014,"Settlement agreement entered in May, 2014. Withdrawal of Revocation and Condition. Sent 12/23/2014.",3,0,,, +CO14041,517120,AFH,2/18/2014,"On February 18, 2014, the licensor made an unannounced visit to the licensee's adult foster home (AFH). Upon arrival caregiver (LG) and Resident Manager (EL) were present in the home. The licensor discovered that EL's last approved criminal background check was 1/16/2013. EL had been working in the AFH without an approved criminal background check for approximately one month. The licensee's conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,200,,, +HB116506,517155,AFH,3/10/2011,RP2 had inappropriate physical contact with RV sometime between 2/16/11 and 3/2/11. RP2 has been permanently removed from Licensee's.,2,0,,, +CO13110,517166,AFH,3/13/2013,Licensee admitted a resident and administered tasks that requires a nursing delegation. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated. UPDATE: FOP sent 7/30/14.,3,200,,, +ES133886B,517166,AFH,7/23/2013,"It was reported that on or about July 23, 2013, Licensee failed to assess and interve as Resident #1 (RV1s)health statuss had changed. Licensee failed to properly car plan around RV1s behaviors and failed to implement interventions as RV1 condition changed. Licensee's failuers are a violation of Oregon administrative Rules (OARs).",2,,,, +CO13072,517205,AFH,4/25/2013,"On April 25, 2013, the licensor conducted an annual renewal inspection at the licensee_x001A_s adult foster home (AFH). During the inspection the licensor discovered that two bedrooms located on the second floor of the AFH did not have a smoke detector as required. The licensee failed to install all required smoke detectors. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,500,,, +ES103562,517215,AFH,2/15/2009,"On February 16, 2010 Reported Perpetrator #1 (RP1) determined that 60 doses of one of Resident #1's medication were missing. RP1 also found that the lock mechanism on the medication drawer was defective and could be manipulated without a key. Resident #1 did not miss any doses of the medication. RP1 immediately refilled the medication, fixed the lock and reported the loss to law enforcement as a theft.",2,0,,,Financial abuse +CO11149,517221,AFH,10/7/2011,"The licensor conducted a monitoring visit of the licensee_x001A_s Adult Foster Home (AFH) on September 29, 2011. During the visit, the licensor discovered that Caregiver #1 was working in the AFH and did not have an approved Criminal Records Check. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +MV105863,517221,AFH,10/20/2010,"On or about October 20, it was alleged that Reported Perpetrator #2 (RP2) failed to provide appropriate care to Reported Victim (RV). It was determined RP2 documented administering more Lorazepam to RV then what was ordered by the physician. The licensee failed to keep the medication record accurate for RV. The failure is a violation of Oregon Administrative Rules.",0,0,,, +AL120189A,517232,AFH,12/19/2011,"On or about December 19, 2011, Licensee failed to administer Resident #1's (RV1) medications as ordered. RV1 didn't always swallow his/her medications and at times would refuses his/her medications. RV1 has been known to hide medications, throw medications on the floor and in the garbage. Licensee failed to ensure Resident #1 took his/her medications when administered, failed to notify Resident #1's physician when he/she refused medications, and failed to document Resident #1's refusal of medications. Licensee's failures are a violation of Oregon Administrative Rules (OARs), are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",3,400,,,Neglect +AL120189B,517232,AFH,12/19/2011,"It was reported that on or about December 19, 2011, Licensee failed to keep a accurate medication administration record (MAR) for Resident #1 (RV1). Licensee failed to document refused medication on RV1's MAR. Licensee's failures are a violation or Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +AL120189C,517232,AFH,12/19/2011,"It was reported that on or about December 19, 2011, Licensee failed to intervene when Resident #1's (RV1) condition changed. RV1 frequently refused his/her medications or would attempt to hide his/her medications. Licensee failed to notify RV1's physician that RV1 was refusing medications. Licensee's failures are a violation or Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +AL120189D,517232,AFH,12/19/2011,"It was reported that on or about December 19, 2011, Licensee failed to follow Resident #1's (RV1) care plan. RV1's care plan indicated that he she was to have a low salt diet. Licensee fed RV1 processed foods and canned foods known to be high in sodium. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +AL121680,517232,AFH,8/14/2012,"It was reported that on or about August 14, 2012, Licensee failed to intervene when Resident #1's condition changed. On August 14, 2012, Resident #1 had a significant change in his her health condition. Licensee and Reported Perpetrator #2 failed to intervene when Resident #1's health condition required immediate medical intervention. Licensee's failures are a violation of Oregon Administrative Rules and constitute abuse. Wrongdoing on the part of the Licensee was substantiates.",0,400,Substantiated,Substantiated,Neglect +ES152508A,517269,AFH,8/18/2015,"On or about August 18, 2015, the Department received a complaint which alleged the facility had limited Resident #1's (RV) access to a telephone. + +As part of the investigation, the Adult Protective Services Specialist (APSS) interviewed multiple witnesses who reported that Licensee (RP2) and RP2_x001A_s staff had removed RV_x001A_s telephone on more than one occasion because RV had a history of calling his/her family and complaining. RP2 acknowledged that she would remove the phone and put it in RV_x001A_s closet. RV stated that it made him/her angry when the facility took away his/her telephone. Witness #8 (W8) also stated that RP2 had eavesdropped on RV_x001A_s phone conversations. + +Licensee restricted RV_x001A_s ability to associate and communicate privately with any person of his/her choice. Licensee_x001A_s conduct is a violation of resident rights, is considered involuntary seclusion and constitutes abuse.",2,,Substantiated,Substantiated,Involuntary Seclusion +AL132597A,517286,AFH,12/20/2012,Resident #1's care plan indicated that Resident #1 preferred daily showers and that facility would bathe Resident #1 as needed. Resident #1 stated that his/her shunt would get clogged with body oils and that he/she developed a skin condition because Resident #1 was not being bathed as often as necessary to maintain adequate hygiene. Facility failure is a violation of Oregon Administrative Rule.,2,0,,, +AL132597C,517286,AFH,12/20/2012,Resident #1 had a written order to take Medication #1 first thing each morning. Instructions for Medication #2 indicated that it should be taken separately from Medication #1 by at least 30 minutes. During the investigation Resident #1 reported that the facility gave him/her all of his/her morning medications just before breakfast. Licensee failed to administer medications per physician's orders. Facility failure is a violation of Oregon Administrative Rules.,2,0,,, +AL132795,517286,AFH,12/20/2012,Resident #1 was prescribed a narcotic pain medication. Staff at licensee's adult foster home did not consistently document each time Resident #1 was administered his/her narcotic pain medication. Facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rule.,2,0,,, +SV105890A,517291,AFH,12/13/2010,"On or about December 14, 2010, it was reported that the Licvensee failed to provide appropriate care to Resident #1 (RV1) and Resident #2 (RV2). Licensee failed to have proper Registered Nurse (RN) delegations for caregivers prior to performing tasks that require RN delegations. It was found that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +SV105890B,517291,AFH,12/13/2010,"It was reported on or about December 14, 2010, that the Licensee failed to provide Resident #1 his/her medications for several days. RV1 was admitted to Licensee's Adult Foster Home (AFH) on December 9, 2010, with one nights supply of medications. The pharmacy did not deliver RV1's medications until December 13, 2010. It was found that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO12032,517291,AFH,12/12/2011,"Licensee failed to protect Resident #1 from financial exploitation. Resident #1 (RV1) moved into Licensee_x001A_s AFH on a private pay basis in March of 2007. RV1 had a representative who handled RV1_x001A_s finances. RV1_x001A_s representative was to pay $2400 on behalf of RV1 each month. In January of 2008, RV_x001A_s representative applied for RV1 to go on Medicaid. By the time RV1_x001A_s representative applied for RV1 to go on Medicaid, RV1_x001A_s private pay rate had increased to $2600 per month. + + + +RV1 was approved for Medicaid effective February 1, 2008. Effective February 1, 2008, RV1_x001A_s portion of the Medicaid rate was determined to be $520.73. RV1_x001A_s representative was unaware that RV1 was approved for Medicaid and paid the Licensee the full private pay amount of $2600 on February 8, 2008, and paid another $2600 on February 25, 2008 for the month of March 2008. Once RV1_x001A_s representative became aware that RV1 was approved for Medicaid and that Licensee had been paid both private pay and Medicaid payments for February and March 2008, RV1_x001A_s representative requested a refund.",3,0,,,Financial abuse +CO11087,517416,AFH,6/25/2011,Licensee transported Resident #1 while intoxicated. Licensee was arrested for DUII.,3,0,,,Neglect +CO11103,517416,AFH,6/25/2011,,4,0,,,Neglect +RB117311,517416,AFH,6/25/2011,"On or about June 27, 2011, it was reported that the Licensee placed Resident #1 (RV1) at risk of serious harm. The Licensee had driven RV1 to the pharmacy and then to a local market. At the local market the Licensee was observed to be intoxicated. Law enforcement was called and the Licensee was cited for Driving Under the Influence of Intoxicants. Wrongdoing on the part of the Licensee had been substantiated.",4,0,,,Neglect +RB118198A,517416,AFH,1/15/2011,"On or about October 10, 2011, it was reported that the Licensee failed to provide a safe medication administration system for Resident #1 (RV1). RV1 moved from Licensee's Adult Foster Home (AFH) on September 18, 2011. Upon moving, RV1 was 3 days short of his/her narcotic pain reliever. Additionally, RV1's remaining pain reliever medication was giving to RV1 in the incorrect packaging when he/she moved. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RB118198B,517416,AFH,1/15/2011,"It was reported on or about October 10, 2011, the Licensee failed to follow physician orders. Resident #1's (RV1) was suppose to receive pain medication as a scheduled medication per physicians order. Licensee gave RV1 his/her pain medication as needed (PRN) instead of scheduled. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO14164,517421,AFH,8/14/2014,,3,200,,, +CO14165,517421,AFH,7/31/2014,FOP sent,2,250,,, +CO15127,517421,AFH,6/24/2015,"During a facility visit conducted on June 16, 2015, the licensor discovered Licensee had caregiver Christine Hammersmith working unsupervised without having completed a preparatory caregiver workbook as required. Licensee_x001A_s failure to have a qualified caregiver present twenty four hours a day constituted a failure to provide a safe environment.",3,250,,, +CO15138,517421,AFH,7/13/2015,,2,250,,, +CO15142,517443,AFH,7/14/2015,Failure to narrate weekly progress for three residents; failure to document activities for three residents; failure to maintain a MAR for two residents; and failure to initial Resident #3's MAR for the pm doses given on 06/09/15 and the am doses on 06/10/15.,2,400,,, +ES118463A,517473,AFH,11/9/2011,"It was reported that on or about November 9, 2011, Licensee failed to assess and intervene when Resident #1's health condition changed. Licensee failed to provide RV1 with appropriate care and services by not following physician orders and failed to update RV1's careplan as his/her condition changed. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES135373,517473,AFH,11/21/2013,"It was reported that on or about November 21, 2013, Licensee failed to provide appropriate care to Resident #1. Resident #1 had slipped of his/her chair while eating breakfast on the morning of November 21, 2013. Licensee transported Resident #1 to the hospital as a result of Resident #1 slipping out of his/her chair. Emergency room discharge documents indicated Resident #1 was not to be left unsupervised after being hospitalized. Licensee took Resident #1 to the pharmacy after being discharged from the hospital and left Resident #1 in the car alone for a minimum of 38 minutes. Resident #1 exited the vehicle independently and fell in the parking lot; Resident #1 sustained a laceration and a bump above his/her left eye as a result of the fall. Licensee's failures are a violation of Oregon administrative rules is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated. UPDATE: FOD COMPLETE 7/30/14 and an e-mail sent to AR requesting the Aging Process begin.",3,400,,,Neglect +MV117167,517499,AFH,6/7/2011,"It was reported on June 6, 2011, that Licensee was yelling and talking to three residents in a demeaning manner. Three witnesses stated they have seen and heard Licensee yelling and speaking to residents in a demeaning way. The Licensee_x001A_s failure is a violation of resident rights.",2,,,, +MV118520B,517499,AFH,11/2/2011,"On or about November 2, 2011, Resident #1 (RV1) fell and sustained a leg fracture. RV1 was prescribed a narcotic pain medication to be dispensed on an as needed basis. RV1 also had a previous order for an over-the-counter pain medication to be given on a scheduled basis. The investigation concluded that the narcotic pain medication was administered eight times between November 4, 2011 and November 6, 2011 and the over-the-counter pain medication was not administered on a scheduled basis as ordered. Licensee's failure to ensure medication was administered as ordered resulted in unreasonable pain to RV1.",2,0,,, +MV118580,517499,AFH,11/28/2011,"On or about November 30, 2011, a report was received alleging that multiple residents at Reported Perpetrator #1's (RP1) adult foster home were not receiving medications as ordered. The investigation concluded that RP1 failed to keep accurate Medication Administration Records (MARs) for Resident #1 (RV1), Resident #2 (RV2), and Resident #3 (RV3). RP1 failed to dispense multiple doses of three different medications to RV1. A minimum of one dose each of two medications was not administered to RV2 as ordered. RP1 was unable to produce the MAR for Resident #4 to verify if RV4's PRN (as needed) pain medication was given as ordered and requested. Facility failed to maintain a safe medication administration system. This failure is a violation of Oregon Administrative Rule.",2,0,,, +MV105333,517499,AFH,9/19/2010,"It was reported that on or about September 19, 2010, Licensee failed to protect Resident's from inappropriate verbal communications. Licensee has yelled at Resident #1 and did come across angry, yelled at Resident #2 and came across irritated and yelled at witness #1 in front of Resident #1 and Resident #2. Licensee's failures are a violation or Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV134362A,517499,AFH,9/6/2013,Licnesee and Caregiver #1 used demeaning language about and directly to Reisdent #1. The Licensee failed to protect the Resident's Right to be treated with respoect and dignity. The Licensee's failure is a violation of Oregon Administrative Rule.,2,,,, +MV134362E,517499,AFH,9/6/2013,Caregiver #1 provided information to emergency medical services personnel that Resident #1 did not need to be transported to the hospital. Licensee failed to ensure Resident #1 was allowed his/her choice of treatment. The Licensee's failure is a violation of Oregon Administrative Rule.,2,,,, +MV134362D,517499,AFH,9/6/2013,Medication administration records did not accurately reflect actual administration of medications for Residents #2 and #5. Licensee failed to document medication administration records at the time of administration. Licensee's failure is a violation of Oregon Administrative Rule.,3,,,, +CO11101,517506,AFH,7/8/2011,,2,250,,, +CO11136,517506,AFH,8/16/2011,Licensee failed to complete 12 continuing education credits as required.,2,200,,, +CO13117,517506,AFH,7/23/2013,Unqualified caregivers UPDATE: FOD complete 6/08/14 and sent to AR requesting the AGING Process begin.,3,500,,, +CO13134,517506,AFH,11/9/2013,Licensee failed to provide a safe and secure medication administration system.,3,0,,, +GP134987A,517506,AFH,11/7/2013,"It was reported that on or about November 7, 2013, Licensee failed to protect Resident #1 from inappropriate verbal comments. Licensee was verbally abusive to Resident #1 calling him/her ""stupid"" and would mock Resident #1. Licensee's failures are a violation of Oregon administrative rules and is considered verbal/mental abuse. Wrongdoing on the part of the Licensee has been substantiated.",2,,,, +GP134987B,517506,AFH,11/7/2013,"It was reported than on or about November 7, 2013, Licensee failed to provide appropriate care to Resident #2 (RV2). Licensee failed to maintain RV2's daily hygiene care needs. Licensee's failures are a violation of Oregon Administrative Rules, are considered neglect and constitute abuse. Wrongdoing on the part of the License is substantiated.",2,,,,Neglect +GP135072,517506,AFH,11/14/2013,"On or around 11/12/13, APS received an allegation that the facility failed to administer medications as prescribed. Upon conducting an investigation, APS determined that the facility was not giving medications, as prescribed by a physician, to Residents 1 and 2. The facility's failure to follow doctor orders is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +GP104464A,517534,AFH,6/3/2010,"On or about June 4, 2010 it was reported RV's folded wheel chair and walker were placed against his/her bed to prevent him/her from getting out of bed at night. This presented him/her with potential for harm in the event he/she had attempted to move the items or climb over them. RV usually had to get up twice per night to use the restroom.",2,0,,, +DA105878,517542,AFH,11/15/2010,"It was reported that on or about October 2010 through November 2010, Licensee failed to provide a safe medication administration sysytem. Licensee's failures are a violation of resident rights and a violation or Oregon Administrative Ruls (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,,,, +DA117798A,517542,AFH,8/14/2011,"On or about August 18, 2011, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) verbally mistreated Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3) and Reported Victim #4 (RV4). It was determined that RP1 used derogatory and inappropriate language toward RV1, RV2, and RV3. Licensee failed to protect RV1, RV2, and RV3 from verbal abuse.",2,0,,,Verbal/Mental abuse +HB120280,517550,AFH,6/8/2012,"On or about June 8, 2012, it was reported that the Licensee failed to protect RV from financial exploitation. RP2 admitted to the theft and use of RV2_x001A_s narcotic medication.",3,0,Not Substantiated,Substantiated,Financial abuse +CO12007,517553,AFH,10/7/2011,"The licensor conducted a renewal visit to the licensee_x001A_s Adult Foster Home (AFH) on July 21, 2011. Caregiver #1 was on duty during the visit. During the renewal the licensor discovered that caregiver #1 had not completed the Caregiver Preparatory Workbook. The licensee has shown a history of noncompliance based on recent related violations regarding unqualified caregivers (see violations dated January 29, 2010 and March 22, 2010).The licensee_x001A_s failure to have a qualified caregiver on duty is a violation of Oregon Administrative Rules.",2,200,,, +MV129959,517553,AFH,5/3/2012,"On or about May 3, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from financial exploitation. RP is RV's rep payee through Social Security. RV's bank account has been overdrawn on multiple occasions. March 26, 2012 bank statement was -$151.00. April 23, 2012 bank statement was -$513.00. Overdraft charges of $7 per day for RV's bank account occurred on 3/27, 3/28, 3/29, 3/30, 4/2, 4/17, 4/18, 4/19, 4/20, 4/23. On April 11, 2012, a charge for a handset from T-mobile for $475.00, on 4/12 and 4/13 insufficient funds fee of $33. RV does not own a cell phone. RP is the only person with access to RV's bank account. The licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights, is considered financial exploitation, and constitutes abuse.",2,0,,,Financial abuse +MV120021,517553,AFH,5/2/2012,"On or about May 2, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate services to Reported Victim (RV). It was determined through interviews that RP handles RV's personal incidental funds (PIF) every month. RP was unable to provide documents to account for RV's PIF. The licensee failed to provide appropriate management of RV's personal funds. The failure is a violation of Oregon Administrative Rule.",2,0,,, +MV132278,517553,AFH,1/23/2013,"On or about January 23, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from financial exploitation. RV is to receive $177.30 a month for h/her Personal Incidental Funds (PIF). RV's PIF is sent to RP to manage. It was determined through interviews that RP did not maintain receipts for RV's PIF as required. The licensee failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO13103,517553,AFH,8/1/2013,UPDATE: FOD complete 6/8/14 and an e-mail had been sent to AR to start the Aging Proces.,3,550,,, +MV120725,517553,AFH,7/30/2012,"On or about July 30, 2012, it was alleged that Reported Perpetrator (RP) failed to administer an ordered medication to Reported Victim (RV). It was determined that RV received a prescription for pain medication on 7/20/2012 by the hospital. The pain medication was not appropriately documented on RV's medication administration record. The adult foster home discontinued the pain medication without an appropriate discontinue order. The licensee failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14034,517553,AFH,2/3/2014,Voluntary surrendered license - revocation not needed,4,,,, +MV146074,517553,AFH,2/12/2014,"The licensee (RP) manages Resident #1_x001A_s (RV1) personal incidental funds (PIF). RV1 is to receive his/her PIF every month. Both RV1 and RP acknowledged RV1 receives $176 per month in PIF. RV1 stated that RP does not spend the entire $176 each month and RV1 does not receive what is left of the PIF each month. RV1 has been at RP_x001A_s for at least two years. Witness #2 (W2) shops for RV1 but stated that he/she has not received any money from RP1. W2 stated that W2 maintains receipts of what he/she has spent and what RP1 still owes RV1. According to W2, RP owes RV1 $197.90 dating back to September, 2013. A tracking form for RV1_x001A_s PIF shows that between 11/7/13-2/6/14 RP1 owes RV1 $139.23 + + + +Reported Perpetrator #2 (RP2) is Resident #2_x001A_s (RV2) rep payee. RV2 stated that he/she has been having problems with his/her money. RV2 stated that he/she has not received any money from RP1 or RP2 since October 7, 2013. RV2 continued to say that he/she has not seen RP1 since September 2013. RP1 stated that RV2 has not received his/her social security checks and that is why RV2 has not received his/her money. According to RP1, RV2 receives $156 in PIF each month. RP1 acknowledged that RV2 has not received his/her PIF since October 2013. RP2 acknowledged that he/she has not maintained any record of where RV2_x001A_s money has gone. + + + +Resident #3 (RV3) stated that Witness #3 (W3) handles RV3_x001A_s money and RV3 has not received any money recently. Witness #3 sends $2200 each month to RP1 for rent and an additional $50 each month for RV3_x001A_s spending money. RP1 does not have an accounting of where the money has gone. W3 has been sending money to RP1 for approximately a year and a half. + + + +The licensee failed to protect RV1, RV2 and RV3 from misappropriation of funds. The licensee_x001A_s failure is a violation of resident rights, is considered financial exploitation, and constitutes abuse. UPDATE: FOD Complete 7/29/14 and e-mailed AR requesting the Aging Process begin.",3,400,,,Financial abuse +CO14121,517553,AFH,7/7/2014,Suspension issued - licensee's name no longer appears on lease or utilities.,4,,,, +MV146929,517553,AFH,4/13/2014,"On or around 4/21/14, Adult Protective Services (""APS"") received a complaint that the facility failed to provide proper care to a resident (""RV""). During the course of the investigation, APS found that RV feel on 4/13/14, in the morning. RV had difficulty getting up after the fall and attempted to get help by notifying a resident in another room by banging on the wall. Although RV did not receive help from that resident, a third resident (""W3"") assisted RV in getting off the floor and into bed. Both RV and W3 notified facility staff the next morning. Staff took notice of the injury but did not assist in seeking medical attention until 4/17/14. Resident records are not timely and none exist from 2/1/14 to 4/4/14 and from 4/11/14 to 4/16/14. RV had a sprained wrist. Facility's failure to promptly seek medical attention for RV is a violation of resident rights and Oregon Administrative Rule, constitutes neglect, and is considered abuse.",3,400,,,Neglect +MV105876,517555,AFH,11/9/2010,"On or about November 9, 2010, it was alleged that Reported Perpetrator (RP) failed to provide a safe and secure environment for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). It was determined that RP failed to adequately assess and intervene resident's behavior.",2,0,,, +MV116030,517555,AFH,12/12/2010,"On or about December 12, 2010, it was alleged that Reported Perpetrator #2 (RP2) failed to protect Reported Victim #1 (RV1) from inappropriate verbal comments. It was determined that RP2 called RV1 a ""liar"" and a ""fake"" which resulted in RV1 crying and feeling emotional distress. Reported Perpetrator #1 (RP1) failed to protect RV1 from loss of dignity. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV120052A,517555,AFH,5/11/2012,"On or about May 11, 2012, it was alleged that Reported Perpetrator failed to administer medication as ordered to Reported Victim#1 (RV1). RV1 was transported to the hospital and had 4 pills with h/h that RV1 said RP2 administers to h/h as h/h narcotic pain medication. It was discovered that the 4 pills that RV1 had were Tylenol and not RV1's narcotic pain medication. It was determined through interviews and observations that Reported Perpetrator#2 (RP2) was not administering RV1's narcotic pain medication as ordered. The licensee failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rule.",2,0,,,Financial abuse +MV120052B,517555,AFH,5/11/2012,"On or about May 11, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3) and Reported Victim #4 (RV4) from inappropriate verbal comments. It was determined through interviews that Reported Perpetrator #2 (RP2) sometimes yells at RV's. The licensee failed to protect RV's from loss of dignity. The failure is violation of Oregon Administrative Rule.",2,0,,, +CO13070,517555,AFH,5/7/2013,"On May 7, 2013, a monitoring visit was conducted by the licensor at the licensee's adult foster home (AFH). Resident Manager AU was present upon arrival. During the visit AU disclosed to the licensor that unqualified care giver Nathalie Hernandez provided care alone to residents from approximately 5:00pm to 8:00pm at least one time during the week of 4/29/2013. Nathalie Hernandez had not been oriented to the AFH, had not completed the caregiver preparatory workbook and did not have a cleared criminal records check as required. The licensee failed to have a qualified caregiver on duty at all times. The licensee's conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +MV120544A,517555,AFH,7/16/2012,Apportioned to RP2 on 9/19/20d13-SG,3,,,,Physical Abuse +MV120544B,517555,AFH,7/16/2012,"On or about July 16, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV smelled of urine and feces on multiple occasions. RV's dentures was observed to be unclean and had not been taken out of RV's mouth for a prolonged period of time. RV's care plan dated 5/26/12 through 6/20/2012 notes that RV was to be bathed 1x per week or as needed. RV's progress notes dated 4/17/2012 through 7/07/2012 state that RV received two shower/bed baths. Witness #5 (W5) stated that within the last two years W5 was not able to take out or clean RV's dentures due to RV's combative behavior. W5 and Witness # 7 (W7) requested additional assitance from RP to meet RV's care needs. RP did not provide any additional assistance. The licensee failed to provide appropriate care to RV. The failure is a violation of resident rights and constitutes abuse.",2,,,,Neglect +CO14033,517555,AFH,2/3/2014,Voluntary surrender - Revocation not needed,4,,,, +MV118488,517555,AFH,11/14/2011,"On or about November 18, 2011, it was alleged that Reported Perpetrator (RP) failed to provide appropiate service to Reported Victim (RV). RP manages RV's person incidental funds (PIF). On at least one occasion RV wanted to purchase a personal item and could not get a hold of RP to get the PIF to make the purchase. RP acknowledged that he/she does not maintain records for RV's PIF. The licensee failed to provide appropriate service to RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +DA150281,517609,AFH,1/22/2015,"On or about January 22, 2015, the Department received a complaint which alleged the facility had failed to follow physician's orders for Resident #1 (RV1), Resident #2 (RV2), Resident #3 (RV3) and Resident #4 (RV4). The investigation determined that RV1 was not dispensed four different medications for at least two months; RV2 was out of two medications for over two months; one medication for RV3 was not available at the facility for two months; and RV4 missed one or more doses of four medications in January 2015. Licensee (RP1) and Reported Perpetrator #2 (RP2) acknowledged that the facility ran out of multiple medications. RP2 also reported that he/she didn't keep track of things or pick-up resident medications because she didn't have time. A nursing note for RV1 dated January 22, 2015 documented that RP1 and RP2 had been taught the risks of not having medications on hand. Licensee and RP2 failed to ensure that the medication regimens for RV1, RV2, RV3 and RV4 were carried out as ordered and accurately documented as required under Oregon Administrative Rule. Licensee's failure to ensure that all medications were available and administered as ordered is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +DA133976,517611,AFH,7/28/2013,"Resident #1 had surgery on May 14, 2013 to repair his/her broken ankle. Resident #1_x001A_s follow-up appointment with his/her medical professional was scheduled for May 28, 2013. The May 28, 2013 follow-up appointment with Resident #1_x001A_s healthcare provider was canceled by the adult foster home (AFH) due to insufficient facility staffing. Resident #1_x001A_s follow-up appointment was re-scheduled for July 11, 2013 but was canceled when Trip-Link_x001A_s vehicle experienced mechanical difficulties. Resident #1_x001A_s follow-up appointment was next scheduled for July 17, 2013 but was again canceled by the AFH due to insufficient staffing. Resident #1_x001A_s follow-up appointment occurred on July 26, 2013. + + + +The investigation further determined that Reported Perpetrator #2 (RP2) failed to immediately and properly dispose of syringes in a secured sharps container which created an unsafe environment for Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5. + + + +Licensee failed to provide appropriate care and services to all residents. Licensee_x001A_s failures violate Oregon Administrative Rule.",2,,,, +DA149606A,517611,AFH,12/16/2014,"On or about December 16, 2014, a complaint was received that alleged the Licensee had failed to properly manage Resident #1_x001A_s (RV) medications. Resident #1 was prescribed Medication #1. Medication #1 was critical to Resident #1_x001A_s health. Resident #1 was to be administered one dose in the morning and one dose in the evening. Resident #1 was dispensed the morning dose but not the evening dose. Resident #1_x001A_s medical professional stated that Medication #1 must be administered correctly so that his/her body would not reject his/her new kidney. A letter from Witness #3 (W3) was reviewed. The letter dated December 16, 2014 indicated that in September 2014 Resident #1 was not being administered his/her Medication #1 correctly. As of the December 15, 2014, Resident #1 had another appointment during which it was again noted that Resident #1 was not getting his/her Medication #1 administered correctly. + + + +Resident #1 was also prescribed Medication #2 which was to be given one hour prior to his/her meals or other medications. A written report dated December 17, 2014 indicated that Resident #1_x001A_s thyroid level was _x001A_too high_x001A_ and that it was a result of receiving his/her medication at the same time as his/her other medication. Witness #3 further reported that AFH staff had been advised that Medication #2 must be given one hour before other medications so it absorbs correctly. + + + +During the course of the investigation, Witness #2 acknowledged that there had been some _x001A_mistakes_x001A_ with Resident #1_x001A_s medications. Licensee (RP) also acknowledged that she had had some difficulty with Resident #1_x001A_s medications. + + + +Licensee failed to have a safe medication administration system which placed Resident #1 at risk of serious harm. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +DA149606B,517611,AFH,12/16/2014,"On or about December 16, 2014, a complaint was received that alleged the Licensee had failed to properly manage Resident #1_x001A_s diet requirements. Resident #1_x001A_s Medication Administration Record (MAR) dated July 7, 2014 indicated that Resident #1 was allergic to oats, gluten. Resident #1_x001A_s service plan dated August 8, 2014 also listed Resident #1 was allergic to oats and that he/she required a gluten-free diet. Witness #1 also reported that Resident #1 must have a gluten-free diet due to Resident #1 disease process. During the course of the investigation, RV reported that he/she did not receive food that met his/her restricted diet. Observations of a facility menu for Monday (no date) revealed that breakfast consisted of quiche and English muffin, lunch was listed as including hot dog, chips, potato salad and Jell-O; chocolate chip cookies were offered as a snack and the dinner was listed as tuna casserole, peas with noodles, crackers and grapes. The investigator noted that menus for other days of the week contained similar menu items. + + + +Licensee failed to provide a therapeutic diet for Resident #1 which resulted in Resident #1 experiencing chronic diarrhea. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +CO15017,517611,AFH,2/2/2015,Violations written 10/20/14 are not clear. Pictures of MARs are either cut off or blurry. Janelle/NWSDS had requested a mandatory civil penalty for falsification. There is no clear (whether photo or written) evidence that I could use to support a civil penalty. Licensee surrendered her license immediately after a suspension was served.,2,,,, +DA159940B,517611,AFH,1/13/2015,"On or about January 15, 2015, the Department received a complaint which alleged the Licensee had failed to provide a safe medication administration system for Resident #1 (RV). RV required a complex medication regimen that included many medications, including ones to minimize the risk of organ rejection. During the course of the investigation, Witness #1 (W1) reported that the facility had ran out of one or more of RV's medications on more than one occasion. Reported Perpetrator #2 (RP2) acknowledged that RV's medications are ""hard to figure it all out"". Witness #3 (W3) reported that RP2 was unsure what to do with RV's medications. RV's Medication Administration Record (MAR) for January 2015 documented that RV failed to receive all ordered medications or received the incorrect dose on more than one occasion in January 2015. Licensee failed to follow physician's orders, failed to maintain stock of all ordered medications and failed to document all required information on RV's MAR for January 2015. Licensee's failure to provide a safe medication administration system placed RV at risk of serious harm. The failure is a violation of resident rights , is considered neglect and constitutes abuse.",3,,,,Neglect +DA150241A,517611,AFH,2/11/2015,"On or about February 11, 2015, the Department received a complaint that alleged Licensee had failed to ensure timely medical treatment for Resident #1 (RV). During the course of the investigation, RV stated that he/she had requested the facility contact his/her medical provider due to pain but the facility had failed to do so. Later RV called his/her physician who directed RV to go to the emergency room. RV had a friend of his/her take RV to the medical facility where it was confirmed that RV had an infection. Upon discharge from the medical facility on February 5, 2015, RV was prescribed two medications. The prescriptions were not filled until early to mid afternoon on February 6, 2015. Witness #2 (W2) provided a copy of RV_x001A_s Medication Administration Record (MAR) for February 2015 to the investigator. The MAR indicated that one of the medications was administered at 1pm on February 6, 2015. However, evidence obtained during the investigation indicated that the medications did not arrive at the adult foster home (AFH) until approximately 3pm on February 6, 2015. The Licensee failed to ensure that RV's medical professional was contacted in a timely manner, failed to obtain ordered medications for RV in a timely manner and failed to maintain accurate resident records. Licensee's failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +DA150241B,517611,AFH,2/11/2015,"On or about February 11, 2015, the Department received a complaint that alleged the facility had failed to protect Resident #1 (RV) from inappropriate verbal communication. RV stated that he/she overhead Licensee (RP1) tell Reported Perpetrator #2 (RP2) that she was ""really pissed off"" that ""they wasted a transplant"" for RV while her friend died waiting for one. During the course of the investigation, RP2 confirmed that the reported conversation had taken place. Witness #5 related a separate event in which RP2 told RV that it was his/her fault that the facility was closing. Witness #5 reported that afterwards, it took several minutes for RV to calm down from the interaction. Facility failed to treat RV with respect and dignity and failed to provide a safe environment. Licensee's failure is a violation of resident rights and constitutes emotional abuse.",3,,,,Verbal/Mental abuse +WB116025,517665,AFH,11/29/2010,"On or about November 29, 2010, it was alleged that Reported Perpetrator #1 (RP1) failed to keep medication administration record current or accurate for Reported Victim #1 (RV1). It was determined that the physician order for a medication for RV1 was to be administered when RV1 wakes up and one at 2pm. The Medication Administration Record indicated that this medication was being administered 200mg dose 3x daily. This discrepancy went on for 28 days. The licensee failed to keep RV1's medication record current and accurate. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV132556,517665,AFH,2/22/2013,"On or about February 22, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to administer an ordered medication to Reported Victim (RV). RV's physician order dated for February 2013 stated that RV was to receive furosemide 20mg every other day. On 2/22/2013 RP received a signed physician order that stated RV was to receive furosemide 20mg every day for seven days. Reported Perpetrator #2 (RP2) did not order the medication when h/she received the signed physician order on 2/22/2013. The medication was not ordered until 2/26/2013 by Witness #1 (W1). It was determined that the licensee failed to administer medication as ordered to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14052,517665,AFH,3/7/2014,Condition Withdrawn 5/2/14,4,0,,,Sexual abuse +WB148900A,517665,AFH,10/14/2014,"During a facility complaint investigation that was conducted on or about October 14, 2014, the investigator discovered that Reported Perpetrator #2 (RP2) had used profane language in his/her interactions with or in the presence of Resident #1 (RV1), Resident #2 (RV2) and Resident #3 (RV3). Additionally, Witness #1 (W1), Witness #3 (W3) and Witness #4 (W4) also reported that RP2 had yelled at individuals in the AFH. RV1 stated he/she was stressed by being yelled at and mentioned that his/her medical provider was going to dispense medication to assist with his/her anxiety. During the course of the investigation, RV3 reported that he/she was afraid of RP2 and retaliation. Licensee failed to provide a safe and secure environment for RV1, RV2 and RV3. Licensee's failure is a violation of Oregon Administrative Rule. Responsibility for the inappropriate verbal interactions which rose to the level of verbal/emotional abuse was apportioned to RP2.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +WB149250A,517665,AFH,11/14/2014,"On or about November 14, 2014, a complaint was received that alleged the facility had failed to protect Resident #1 (RV) from rough treatment. During the course of the investigation, Reported Perpetrator #2 (RP2) admitted that he/she had shoved RV on the forehead which knocked RV back onto a sofa. RP2 further stated that he/she was frustrated with RV. Witness #2 and Witness #3 reported that RP2 had been rough with RV on more than one occasion. Responsibility for the physical abuse of RV was apportioned to RP2. It was further determined that the facility had failed to provide a safe environment. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Physical Abuse +WB148312,517665,AFH,8/27/2014,"On or about August 27, 2014, it was alleged that Reported Perpetrator (RP) failed to intervene when Reported Victim's (RV) condition change. On 8/19/2014 RV was found to have sores on the inside of his/her groin area that was caused by urination. RV laid in bed for approximately two days and ate very little food. Witness #2 (W2) visited RV on 8/27/2014, due RV's physical condition and appearance W2 advised RP to transport RV to the hospital. RV was admitted to the hospital where it was discovered that RV was dehydrated and had a urinary tract infection (UTI). RP failed to notify appropriate personnel of RV's change of condition and failed to provide appropriate care to RV. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +WB150712,517665,AFH,11/15/2014,"On or about November 15, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim (RV) from financial exploitation. Prior to RV's passing, RV listed RP2 as the sole beneficiary on RV's will. RV's will was signed 10/18/2014. RP2 received money from RV's estate. According to Witness #1, RP1 and RP2, RV had capacity and the ability to make his/her own decisions. The licensee failed to provide a safe enironment. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14098,517686,AFH,5/27/2014,"The Dept seeks non-renewal for 4 reasons: (1) incomplete renewal application; (2) two or more instances of employing individuals without approved background checks; (3) failure to maintain substantial compliance with the OARs and failure to correct violations in a timely manner; and (4) two instances of substantiated abuse which threatened the health, safety, and welfare of residents.",3,0,,, +CO14183,517686,AFH,9/19/2014,"The Department will place a condition on the home because Licensee has failed to submit a complete, timely renewal application; failed to obtain an approved background check for individuals on more than one occasion; failed to maintain a substantial compliance with OARs to correct violations in a timely manner; and failed to protect the health, safety, and welfare of residents. A Notice of the Department's Intent not to renew license was signed on Sept. 18, 2014, and served same day.",3,0,,, +ES116730,517731,AFH,4/8/2011,"On April 8, 2011, Resident #1 (RV1) had two pain medications missing and Resident #2 (RV2) had two pain medications missing at the end of Reported Perpetrator 2's (RV2) shift. Facility failed to ensure a safe environment for RV1 and RV2.",2,0,Not Substantiated,Substantiated,Financial abuse +MS159933,517740,AFH,1/15/2015,"On or about January 15, 2015 the Department received a report that alleged Resident #1 (RV) had sustained multiple injuries to RV_x001A_s face and head. + + + +During the course of the investigation, the investigator observed that RV had damage to the skin in the area above RV_x001A_s right brow and under RV_x001A_s right eye. It was also documented that RV had faint yellow and brown skin discolorations around RV_x001A_s right temporal area. The skin discoloration covered approximately half of RV_x001A_s forehead. + + + +Licensee (RP1) acknowledged to the Department_x001A_s investigator that RV was found face down on the floor beside RV_x001A_s bed at approximately 7am on the morning of January 15, 2015. The injuries that were observed in the area over RV_x001A_s right brow and under RV_x001A_s right eye were attributed to this un-witnessed fall. Both RP1 and Reported Perpetrator #2 (RP2) reported that RV did not complain of pain after the fall and they each acknowledged that RV_x001A_s medical professional was not contacted immediately. It was only after a visitor to Licensee_x001A_s adult foster home (AFH) had witnessed RV_x001A_s injuries that RP1 contacted RV_x001A_s family and RV_x001A_s doctor. + + + +RP1 and RP2 both reported that RV had also experienced an un-witnessed fall two weeks prior that resulted in the skin discolorations observed on RV_x001A_s forehead. No incident report or other facility documentation was located regarding this fall. RP2 stated that neither RP1 nor RP2 sought medical treatment for RV after this fall. + + + +Additionally, RP1 reported that RV had a history of similar falls. The most recent incident report located for RV documented a fall RV experienced on November 28, 2014 when RV was found on the floor at approximately 7:30am. A progress note dated November 28, 2014 stated, _x001A_When I was helping [her/him] up I noticed a large bruse [sic] on [her/his] right arm that goes from [her/his] elbow to [her/his] sholder [sic] and was swollen. It hurts to touch_x001A__x001A_ + + + +RV_x001A_s most recent Care Plan was reviewed by the Department. The Care Plan dated October 7, 2014 did not address fall interventions despite multiple falls experienced by RV from November 28, 2014 to January 15, 2015. RP1 acknowledged RV_x001A_s history of multiple falls. + + + +Licensee failed to complete an incident report for the fall that occurred at approximately the beginning of January 2015; Licensee failed to update RV_x001A_s Care Plan as RV_x001A_s care needs changed; Licensee failed to notify RV_x001A_s medical professional and family when RV_x001A_s health status or physical condition changed; and Licensee failed to provide a safe and secure environment for RV. + + + +Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,400,,,Neglect +HB129513,517769,AFH,3/15/2012,"On or about March 19, 2012, urine from Resident #1's (RV1) catheter bag spilled onto the floor and furniture. Reported Perpetrator #1 (RP1) told RV1 that he/she should charge RV1 a $500.00 fine for this occurrence. Witness #2 (W2) and Witness #3 (W3) visited RV1 shortly after the incident. W2 and W3 found RV1 crying, upset, and frightened that RP1 was going to evict RV1 from the home. The facility failed to provide a safe environment for RV1. The failure is a violation of residents rights and consistutes verbal abuse.",2,0,,,Verbal/Mental abuse +DA134556A,517782,AFH,9/27/2013,"On or about September 30, 2013, it was alleged that Reported Perpetrator (RP) failed to keep Reported Victim's (RV) medication administration record (MAR) accurate. RV was prescribed Gemfibrozil 600mg two times daily on 4/18/2013. RV's MAR for September 2013 was initialed as Gemfibrozil 600mg three times daily. RP states that this was done in error and that RV received the medication two times daily as prescribed. The licenee failed to keep RV's MAR current and accurate. The failure is a violation of Oregon Administrative Rule.",2,,,, +DA134556B,517782,AFH,9/27/2013,"On or about September 30, 2013, it was alleged that Reported Perpetrator (RP) failed to assure adequate equipment for Reported Victim #2 (RV2). RP was shown how to properly operate RV2's BiPap machine on March 21, 2013, by Witness #2 (W2). W2 made multiple visits to the adult foster home (AFH) after March 2013 because RP did not fully understand how to operate the machine. RP reported that RV2's BiPap machine was not working on September 26, 2013. W2 made a visit to the AFH on September 26, 2013, to drop off a new BiPap machine. W2 observed the maching that was not functional and discovered that the machine had no water in it and the filters had not been changed as required. As a result RV2 had difficulty breathing and wasn't getting enough oxygen. The licensee failed to adequately maintain RV2's equipment. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +CO14090,517782,AFH,5/9/2014,Licensee had caregivers working in the home alone without an approved criminal background check. Licensee was not living in the home and did not have an approved RM or other primary caregiver living & working in the home.,3,900,,, +CO14210,517782,AFH,9/26/2014,"Local licensing authority submitted non-renewal sanction request. Provider has submitted incomplete renewal, has again allowed a caregiver to work without an approved background check and again does not have an approved primary caregiver. Provider has not corrected violations or submitted statements of correction. Provider has not paid a civil penalty.",3,,,, +MS118445,517806,AFH,11/14/2011,"It was reported that on or about November 14, 2011, Licensee failed to protect Resident #1 (RV1) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) had an inappropriate verbal interaction with RV1. The interaction between RV1 and RP2 left RV1 feeling belittled and humiliated. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BH147698,517823,AFH,10/25/2013,"The Department received an allegation that the facility failed to treat RV with dignity and respect. While there was some information that RP1 made comments about RV coughing to much as a behavior issue and yelling at RV. RP1 denied all the allegations, and the allegation could not be corroborated.",,,Substantiated,,Verbal/Mental abuse +CO11006,517856,AFH,10/25/2010,,0,0,,, +ES121169,517906,AFH,9/26/2012,"On or about September 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from financial exploitation. It was determined on August 29, 2012, Reported Perpetrator #3 (RP3) signed for the receipt of 45 pills of RV's pain medication. RP1 cannot account for RV's 45 missing pain medication pills. A urine analysis was conducted for RV on September 22, 2012. The Urine analysis came back negative for RV's pain medication. The licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Financial abuse +FL134293,517906,AFH,9/3/2013,"On or about September 3, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). RV1 is prescribed a pain and anxiety medication. The medication administration record (MAR) for RV1 notes the pain and anxiety medication were signed out on the narcotic sheet but were not initialed as being administered on the MAR. In June of 2013, RV1 received a prescription to increase the dosage for one of RV1's pain medications. According to RV1's MAR, RP did not increase the dosage for approximately two weeks after the prescription was given. RV2 was prescribed a pain and anxiety medication on an as needed basis (PRN). According to RV2's MAR, RV2 was being administered both PRN pain and anxiety meidcations as a scheduled medication. The licensee failed to provide a safe medication administration for RV1 and RV2. The failure is a violation of Oregon Administrative Rules.",2,,,, +FL134976,517906,AFH,11/4/2013,"On or about November 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim (RV). RV was admitted to RP1's adult foster home (AFH) on 10/10/2013. Reported Perpetrator #4 (RP4) picked up a prescription for #180 narcotic pain medication pills for RV on 10/18/2013. RV typically takes four pain medication pills per day with a fifth pill three to five times a month. On 11/4/2013 at 10:00pm RV was told by Reported Perpetrator #3 (RP3) that RV would not be receiving his/her pain medication pill for the 2:00am dose because the facility had run out of the pain medication. RV missed his/her 2:00am pain medication and stated ""it was a hard night to get through."" Reported Perpetrator #2 (RP2) stated that because he/she had been so busy with the licensing application he/she did not have time to conduct a narcotics count or update the medication administration record (MAR) as required. RP2 stated that their were not any missing medications. RP3 stated he/she did not know what happened to the pain pills. Narcotic count sheet dated 11/1/2013-11/6/2013 notes that the pain medication pills were given, then was crossed out and ""error"" was written with the count at 66 pills. RV's MAR for 10/2013 note no medication is signed as being dispensed to RV after 8:00am 10/22/2013 through 10/31/2013. RV's MAR for 11/2013 on one chart indicates no pain medication was administered between 11/3/2013 and 11/9/203. A separate chart indicates no pain medication was given on 11/7/2013 after noon and none given on 11/8/2013, but resumed on 11/9/2013. Nursing medication Notes indicate pain medication was ""not available"" on 11/7/2013. A separate Nursing Medication Notes indicate from 5:00pm on 11/7/2013 through 11/8/2013 at 12:00 midnight RV missed six doses of pain medication due to ""meds not available."" Approximately 95 of RV's narcotic pain medication pills were missing. The licensee failed to provide a safe medication administration system for RV. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,,,,Financial abuse +FL145772,517906,AFH,1/7/2014,"On or about January 16, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim (RV). RV's July 2013 medication administration record (MAR) indicate that Reported Perpetrator #2 (RP2) signed for RV's pain medication #1 (P1) from 7/1/2013-7/3/2013. P1 was listed on the MAR at 10mg as needed (PRN). The MAR for 7/4/2013-7/10/2013 are filled out with the date and time of the doses but are not initialed by any caregiver. The back of the MAR indicates on 7/5/2013-7/7/2013 filled out as P1 administered with the date and time but did not provide a reason for the administration of the PRN medication. The narcotic count sheet dated 12/6/2013-1/2/2014 indicates RV received P1 at 5mg dose at 8pm. On 1/2/2014 it notes that the last P1 was administered to RV at 8pm and the amount remaining was 0. The facility ran out of RV's P1 on 1/2/2014.",2,,,, +FL146451A,517906,AFH,3/20/2014,"On or about March 21, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to administer an ordered medication to Reported Victim (RV). RV is ordered to receive a narcotic pain medication. RV was transferred to the hospital on 3/18/2014. A drug panel screen was conducted by the hospital at approximately 4:50pm on 3/18/2014. The panel showed that RV was negative for the prescribed narcotic pain medication and negative for medication #3. RV's March medication administration record (MAR) indicated RV was administered the narcotic pain medication at 8am, 12pm, 4pm and 8pm from 3/1/2014 through 3/18/2014. March MAR for medication #3 indicated RV received 8pm dose from 3/1/2014 through 3/18/2014. RV's primary physician notes that RV would show a negative drug screen for the pain medication if RV went without the medication for three days. RV did not receive the pain medication or medication #3 as prescribed. The licensee failed to administer an ordered medication. The failure is a violation of Oregon Administrative Rules.",2,,,, +FL146451B,517906,AFH,3/20/2014,"On or about March 21, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from financial exploitation. RV purchased a television from fredmeyer for approximately $299.99 while he/she was living in the facility. RV left the facility. Reported Perpetrator #2 (RP2) stated that RP2 had bought the television from RV before RV left. RP2 did not have a receipt of purchase for the television. RV stated that he/she did not sell the television to RP2. The television was damaged while Reported Perpetrator #4 (RP4) was transporting the television to RV. The licensee failed to protect RV's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14115,517906,AFH,6/12/2014,AFH Home closed on 9/8/2014,4,0,,,Financial abuse +ES147416,517906,AFH,6/13/2014,"On or about June 16, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim (RV) from inappropriate sexual comments. RP2 verbally expressed to RV and Witness #1 (W1) how RP2 would masturbate. W1 stated he/she doesn't like it when RP2 talks like that. W1 asked RP2 to stop making innapropriate comments. RV does not talk with RP2 because RP2 is ""dirty minded."" RP2 denies making any sexual comments toward RV or W1. The licensee failed to protect RV from inappropriate sexual comments. The failure is a violation of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +FL147378,517906,AFH,6/11/2014,"On or about June 12, 2014, it was alleged that Reported Perpetrator #1 (RP1), Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) failed to protect Reported Victim (RV) from financial exploitation. RV stated that he/she loaned RP2 and RP3 $80 dollars and was not paid back. RP2 acknowledged borrowing $80 from RV. RP2 also acknowledged that RP2 and RP3 had over charged RV for care, services and room and board from January 2014 through April 2014. RP2 stated that he/she will pay RV back $60 and the money that RP2 had overcharged. RP2 still owes RV approximately $155.00. The licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights and constitutes abuse.",2,,,,Financial abuse +ES146410,517906,AFH,3/18/2014,"On or about March 18, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate sexual contact. Reported Perpetrator #2 (RP2) works as maintenance personnel at the adult foster home (AFH). RP2 made sexual contact with RV on numerous occasions in RV's bedroom. RP2 denies making any sexual contact with RV. RP2 gradually increased h/h contact and actions with RV. Starting with hugs, and leading to kisses and more physical contact.",4,,Not Substantiated,Substantiated,Sexual abuse +FL148350,517906,AFH,8/29/2014,"On or about August 29, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide a safe environment for Reported Victim (RV). RV was being transferred to another facility. During the day of transfer RV requested all of his/her medications. RV was not provided his/her narcotic pain medication. RP's stated that they were not allowed to give RV the narcotic pain medication and that it would be destroyed. Witness #1 (W1) was able to obtain a new order of narcotic pain medication upon RV's arrival to the new facility. RV was forced to pay $30.00 out of his/her own pocket for the new order of pain medication. RV did not miss any doses of his/her pain medication. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES145721,517906,AFH,1/2/2014,"On or about January 14, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from theft of medications. RV1 had a refill of 180 pain pills on 12/4/13 and 1/3/14. RV2 had pain med refills of 112 on 11/25/13, 12/19/13 and 1/16/14. The medication administration log for RV1 on 1/1/14 notes at 2am the pill count was 28, and at 8am the same day the pill count was 12. The medication administration log for RV2 on 12/19/13 notes there is a count of 112 after a pharmacy refill. The physician order is for one pill four times daily. The adult foster home record documents that RV2 ran out of pain medication on 1/3/14. According to the prescribed dosage, RV2 should have had approximately 52 pills remaining. RV1 stated that ""it is really hard for me to get along without my pain pills."" RV2 stated that he/she has ""a lot of pain"" and that ""it is hard going without the pain pills."" The licensee failed to provide a system that prevents theft or misuse of medication. The failure is a violation of Oregon Administrative Rules.",3,,,, +MV134668,517936,AFH,10/9/2013,"On or about October 8, 2013, Witness #1 (W1) made a visit to the licensee_x001A_s adult foster home (AFH) to see Reported Victim (RV). W1 observed RV in a wheelchair with a belt wrapped around RV, tying h/h to the wheelchair. RV_x001A_s screening and assessment dated October 1, 2013, notes that RV can walk with assistance. RV did not require the use of a wheelchair. Reported Perpetrator #2 (RP2) states that RV was put in a wheelchair because RV kept bumping into walls and sliding off h/h bed and the dining room chairs. RP2 acknowledged that RV was in a restraint but not for more than ten minutes. The licensee failed to protect RV from the wrongful use of a physical restraint. The licensee_x001A_s failure is a violation of resident rights and constitutes abuse.",3,400,,,Restraints +MM134776,517975,AFH,10/17/2013,"On or about October 18, 2013, it was alleged that Reported Perpetrator (RP) failed to provid an adequate medication administration system for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). RP did a count of RV1 and RV2's narcotic pain medication. RV1 received a prescription for 50 tablets of narcotic pain medicaiton on 6/21/2013. It was determined 26 of those 50 pills were missing. Additionally, RV2 was missing 6 of his/her narcotic pain medication.",3,,Not Substantiated,Substantiated,Financial abuse +MM134629A,517975,AFH,10/3/2013,"On or about October 7, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from involuntary seclusion. On one occasion Witness #2 (W2) observed RP tell RV to go into his/her room. RP told RV to stay in his/her room for three or four hours. Witness #5 (W5) stated that RP does send RV to his/her room for long periods of time. RV stated that when RP gets upset then RP sends RV to his/her room. RV also recalled one occasion where RP took RV's food away because RV had not followed directions. W5 stated when RV repeats him/herself, RP will take RV's food away and send RV to h/h room. The licensee failed to protect RV from involuntary seclusion. The failure is a violation of resident rights and constitutes abuse.",2,,,,Involuntary Seclusion +MM134629B,517975,AFH,10/3/2013,"On or about October 7, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. On one occasion Witness #1 (W1) observed RP scream at RV. Witness #2 (W2) observed RP tell RV she/he looked ""stupid."" RP was witnessed calling RV a ""retard"" on multiple occasions. The licensee failed to protect RV against inappropriate, demeaning verbal comments. The failure is a violation or resident rights and constiutes abuse.",2,,,,Verbal/Mental abuse +MS133741,518000,AFH,7/10/2013,"It was reported that on or about July 10, 2013, Licensee failed to provide timely medical treatment to Resident #1 (RV1). RV1 had a fall on June 6, 2013 and RP did not seek immediate medical attention. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MF120279,518038,AFH,6/12/2012,"It was reported that on or about June 12, 2012, Licensee failed to provide an appropriate medication management system for Resident #1 (RV1). RV1 was admitted to the Adult Foster Home (AFH) on June 12, 2012, on June 5, 2012 Witness #1 ordered RV1's narcotic pain medication from the pharmacy so it would be available to RV1 when admitted on June 12, 2012. The medication wasn't delivered to the AFH until 7:00 p.m. on June 12, 2012. As a result of the late delivery RV1 went without his/her morning dose of narcotic pain medication. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +DA120916B,518086,AFH,8/21/2012,"It was reported that on or about August 21, 2012, Licensee failed to provide a safe medication administration system. On at least two occasions Licensee left the medication cabinet unlocked and open. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +DA133143,518086,AFH,5/2/2013,"It was reported that on or about May 2, 2013, Licensee failed to follow physician's orders for Resident #1. Licensee changed Resident #1's medication dose without a physician's order. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV117250,518090,AFH,6/13/2011,"RP1 admitted RV on June 10, 2011 without a delegation to give RV insulin or check bllod sugars. RV was transported to he hospital on June 13, 2011 due to his/her blood sugars.",2,0,,,Neglect +MV116639A,518090,AFH,3/6/2011,Resident #1 and Resident #2 were told by Reported Perpetrator #2 (RP2) on separate occasions to go away when they attempted to wake him/her up for assistance. The facility failed to provide appropriate care and services to Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV116639B,518090,AFH,3/6/2011,"On or about March 10, 2011, a report was received that alleged Reported Perpetrator #2 (RP2) yelled and intimated residents at licensee's adult foster home. The investigation determined that RP2 regularly spoke in a loud and intimidating way when residents requested assistance. Facility failed to provide appropriate care and services. The failure is a violation of Oregon Administrative Rule.",2,0,,, +HB135256,518117,AFH,11/29/2013,"It was reported that on or about November 29, 2013, Licensee failed to provide a safe medication administration system. Licensee's failures are a violation of adult foster home Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +AL148814A,518129,AFH,2/21/2014,"On or about February 21, 2014, it was alleged that Reported Perpetrator (RP) failed to administer an ordered medication to Reported Victim (RV). RV is prescribed an anti-anxiety medication. The medication is to be administered one tablet, twice daily. RV's medication administration record (MAR) notes that RV was not administered the anti-anxiety medication from 2/15/2014 through 2/20/2014. During that time RV exhibited increased anxiety and increased behavior. The licensee failed to administer an ordered medication. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +AL148814B,518129,AFH,2/21/2014,"On or about February 21, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV's medication administration record (MAR) notes that RV did not receive an anti-anxiety medication from 2/15/2015 through 2/20/2014. RV experienced an increase in anxiety during that time. As a result of the increased anxiety RV lit a plastic ornament on fire in his/her bedroom. The fire was put out before alarms were set off in the adult foster home. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB150693,518130,AFH,3/25/2015,"On or about March 25, 2015, the Department received a complaint which alleged that Licensee_x001A_s (RP1) adult foster home had failed to provide appropriate care and services for Resident #1 (RV). RV required assistance with all of his/her activities of daily living and was only able to move his/her hand slightly. RV required ventilator-assisted care twenty-four hours per day, seven days per week. + + + +On or about December 14, 2014, RV used his/her call bell. RV_x001A_s Shift Progress Notes dated December 14, 2014 were reviewed. The document indicated that Reported Perpetrator #2 (RP2) _x001A_did not originally hear the call due to being in another room._x001A_ During the course of the investigation, RP1 acknowledged that a similar incident had occurred in which Reported Perpetrator #3 (RP3) did not hear when RV_x001A_s ventilator alarm had sounded. By the time RP3 reached RV_x001A_s room RV had stopped breathing and was unconscious. RV required resuscitation. RP1 reported that RV_x001A_s room was located toward the back of the house and that they couldn_x001A_t always hear him/her. Licensee failed to provide a safe environment for RV. Licensee_x001A_s failure is a violation of residents_x001A_ rights, is considered neglect and constitutes abuse.",3,450,,,Neglect +CO12016,518150,AFH,12/12/2011,"The licensor conducted a renewal visit at the licensee_x001A_s Adult Foster Home (AFH) on December 12, 2011. During the renewal the licensor discovered that there was no smoke alarm in the licensee_x001A_s bedroom. The licensor also discovered that the smoke detector in an occupant 1_x001A_s bedroom was dismantled and not functional. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,500,,, +CO12017,518150,AFH,12/12/2011,"The licensor conducted a renewal visit at the licensee_x001A_s Adult Foster Home (AFH) on December 12, 2011. During the renewal the licensor discovered that the licensee admitted a resident that was beyond the licensee_x001A_s classification. The AFH is a class II home. The admission screening indicated resident #2 was dependent in 4 activities of daily living and was a level III resident. As of December 12, 2011, the licensee had not requested a classification exception for resident #2. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +CO14160,518157,AFH,8/22/2014,"The Department's local licensing authority conducted a monitoring visit on August 22, 2014. At that inspection, the local licensing authority determined that a caregiver, whose criminal background check had expired, was working alone in the facility. The local licensing authority also determined at this same inspection that there was no primary caregiver living in the home.",3,250,,, +RD121706,518158,AFH,10/19/2012,"It was reported that on or about October 19, 2012, Licensee failed to provide appropriate care for Resident #1. Licensee failed to intervene when Resident #1's condition changed. Licensee failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +RD133635,518158,AFH,6/18/2013,"It was reported that on or about June 18, 2013, Licensee failed to provide appropriate care to Resident #1 (RV1). RV1's care plan last updated on December 1, 2012, stated caregivers were to use a gait belt to assist RV1 when transfering to protect RV1 from falling. On June 18, 2013, Reported Perpetrator #2 (RP2) attempted to transfer RV1 on two occasions without a gait belt resulting in a skin tear to both of RV1's shins. Licensee's failures are a violation of Adult Foster Home (AFH) Oregon Administrative Rules (OARs). RP2's failure to follow RV1s care plan is considered neglect and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +CO16051,518158,AFH,2/4/2016,"Licensee allowed unqualified caregiver to work in the home. Caregiver Aurora Beltran did not have completed workbook, nor signed orientation form. CP sanction granted for $250.00 + $50.00 aggravated factor",3,300,,, +CO15162,518160,AFH,8/14/2015,,2,250,,, +CO16041,518160,AFH,8/12/2015,"Licensee signed MARs for medication as given 8/11-8/13/15. However, medication patch was unavailable on dates signed for. Last given 8/10/15. Mandatory CP issued for falsification of records.",2,150,,, +CO14095,518215,AFH,1/22/2014,UPDATE: FOD Complete 7/29/14 and e-mailed AR requesting the Aging Process begin.,3,250,,, +MS164282A,518215,AFH,10/5/2015,"RP (facility owner) gets frustrated and physically aggressive with RV1. RP slaps RV1 when providing care, slapping RV1 on the bottom and telling RV1 ""see, you're dirty."" RP does not deny slapping RV1. RV1 becomes upset and emotional when discussing RP and how RP talks to him/her. The facility has since closed.",2,,Substantiated,Substantiated,Physical Abuse +MS164282B,518215,AFH,10/5/2015,"RP (facility owner) is loud and demanding with RV1. RP yells at RV1, yelling, ""You need to take a shower!"" or if RV1 is hungry, saying, ""Go to sleep, you already ate!"" in an angry and aggressive way. RV1 is upset and emotional when discussing how RP treats him/her. The facility is now closed.",3,,Substantiated,Substantiated,Verbal/Mental abuse +RS152354,518271,AFH,8/1/2015,"On or about August 1, 2015 RP1 discovered RV1 soaked in urine. RP1 arrived at the adult foster home at 7:50 PM to relieve RP2 of his/her caregiving duties. At approximately 8:30 PM, RV1 was discovered to be soaked in urine. RV1's care plan indicated that he/she holds his/her urine and that RV1 is to be taken to the restroom regularly. The facility failed to provide a safe and home-like environment.",2,,,, +RS152366A,518271,AFH,7/25/2015,"On or about July 25, 2015 it was alleged that the facility failed to protect RV's from inappropriate verbal comments. Multiple Witness statements indicated that RP1 has yelled and raised his/her voice at the adult foster home residents including RV1. Witness #2 indicated that he/she did not make any reports for fear of retaliation. The facility failed to provide a safe and home-like environment.",2,,,, +NB117536B,518272,AFH,7/25/2011,"On or about July 25, 2011, it was reported that the Licensee filed to follow Resident #1's (RV1) and Resident #2's (RV2) care plan. RV1's care plan indicated that he/she was to receive a bath 2 times per week and RV2's care plan indicated he/she was to receive a bath 1-2 times per week. RV1 and RV2 did not receive bathing as scheduled from July 7, 2011 until July 17, 2011. It was found that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +NB129978A,518272,AFH,4/27/2012,"On or about April 27, 2012, Licensee failed to provide a safe medication system for facility residents. Licensee failed to follow physician orders, failed to document the administration of medications and failed to dispose of discontinued medications. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +NB129978B,518272,AFH,4/27/2012,"On or about April 27, 2012, Licensee failed to provide appropriate care for Resident #4. Licensee failed to provide Resident #4 with adequate hygiene care. Licensee's failure is a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +NB129978D,518272,AFH,4/27/2012,"It was reported that on or about April 27, 2012, Licensee failed to provide a safe environment for Resident #1 (RV1). RV1 doesn't always finish his/her meals. Licensee is stern and snaps at RV1 when he she doesn't finish his/her meals as Licensee doesn't like to waste food. Licensee failures are a violation or Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +NB147033B,518272,AFH,5/13/2014,"It was reported that on or about May 13, 014, Licensee failed to provide an appropriate medication administration system. While receiving care from Licensee Resident victim #1 (RV1) did not receive 8 patches of medication ordered for pain. RV1 did have an increase of pain as a result of Licensee's failure to administer the medication. Licensee's failure is a violation of Oregon Administrative Rules is considered neglect and constitutes abuse.",2,,,,Neglect +MV105138,518286,AFH,8/21/2010,"There was a concern that the Licensee and RP2 failed to dispense medications correctly. On August 21, 2010 RV's CBG's were taken at 11:30 PM instead of 9 PM. RV received a medication 1/2 hour late on August 26, 2010. RV was given an incorrect dosage of a medication on August 26, 2010.",1,0,,, +MV152466,518286,AFH,8/12/2015,"RV1 moved to the adult foster home in March of 2015. RV1 was care planned to require assistance with accessing the bus and assuring that he/she was safe. On August 12, 2015 RV1 was located by neighbors of the adult foster home in the intersection of the roadway. RV1 was attempting to get to the bank on his/her own by accepting a ride with A passing vehicle. The facility failed to provide a safe and secure environment for RV1.",2,,,, +CO16048,518286,AFH,3/4/2016,"Licensee had multiple fire life safety violations, knowingly admitted a resident beyond classification of home, and failed to correct multiple violations. Mandatory penalties and general penalties for failures to correct.",3,650,,, +MS117333,518302,AFH,6/29/2011,"On or about June 29, 2011 it was reported that the Licensee failed to provide appropriate care. RV was identified as having weakness and being at risk for falls. RV frequently, did not remember to follow directions unless someone was there to remind RV. RV got up during the night or early morning. There was not always an ""awake"" caregiver to assist RV. RP did not always hear RV when RV got up for assistance. There was no way for RV to call for help - no in room monitor or button. RV did sustain falls, including an unwittneds fall, involving another resident.",2,0,,, +CO11003,518321,AFH,2/23/2010,denied criminal history check at renewal,4,0,,, +CO14105,518331,AFH,1/14/2014,On 5/27/2014 the licensor received information that the licensees criminal background check expired on 1/14/2014. On 5/28/2014 the licensor made a visit to the licensee's adult foster home. The licensee verbally acknowledged that his/her background check had expired on 1/14/2014 and that he/she had submitted a new on 5/27/2014. The licensee operated the adult foster home for approximately five months without a cleared criminal background check. The licensee's conduct constituted a failure to provide a safe environment and failure to maintain qualifications. These failures are a violation of Oregon Administrative Rules.,3,200,,, +CO14099,518425,AFH,5/30/2014,CONDITION #AFHCD14-017 ISSUED BASED ON APS ALLEGATIONS AND PRELIMINARY INFORMATION FROM PENDING APS INVESTIGATIONS. MATTER CONCLUDED ON 08/28/15. WITHDRAWAL LANGUAGE AGREED UPON BY COUNSEL FOR BOTH PARTIES.,3,0,,, +HB146616B,518425,AFH,4/4/2014,"On or about February 19, 2014, Resident #1 (RV) reported that he/she felt pressure on his/her chest. A progress note for RV dated February 19, 2014, documented that RV stated to a caregiver, _x001A_I feel something on my chest_x001A_. Caregiver noted that RV denied both shortness of breath or pain and caregiver left RV_x001A_s room. The progress note further included that, _x001A_Ten minutes later, RV again called caregiver, asking caregiver to tell RP to call the ambulance. RP then went to RV_x001A_s room._x001A_ During the course of the investigation, RP stated that she then went to make copies of some of RV_x001A_s medical records before she called for an ambulance. In the meantime, RV called emergency services him/herself. Emergency services assessed RV and transported him/her to the hospital. + + + +Licensee failed to provide adequate oversight and timely intervention when RV experienced a change in condition. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +HB146616A,518425,AFH,4/4/2014,"Resident #1 (RV) required care interventions to prevent skin irritation and breakdown. RV reported that the facility was to clean the folds under his/her stomach and breasts daily, put powder on his/her skin and place a pillow case in the fold to prevent irritation. During the investigation, RV stated that staff at the adult foster home had told him/her that they didn_x001A_t have time to provide this care on a daily basis. RV reported that it only occurred every 2-3 days and the folds under his/her breasts were only treated on shower days. + + + +Witness #2 (W2) stated that on or about February 3, 2014, facility staff were told by RV_x001A_s home health nurse that RV needed to be turned every two hours to prevent skin breakdown. + + + +On or about February 19, 2014, RV was told by a medical professional that his/her skin was broken out in the fold under his/her breast. RV stated that he/she had experienced pain in that area for some time. + + + +On or about February 21, 2014, a wound assessment showed that RV had blisters and pinkness in his/her groin area. On February 23, 2014, RV was seen by a wound care nurse for moisture-related skin breakdown under his/her breast and a suspected deep tissue injury in his/her left hip (coccyx) area. A home health clinical note dated February 23, 2014 indicated that the importance of turning/repositioning RV at least every two hours had been reinforced. + + + +On or about February 27, 2014, RV complained of pain under one of his/her breasts and W2 found injury to tissue at that location. RV_x001A_s progress note dated February 27, 2014 indicated that RV_x001A_s urine was described as _x001A_tea-colored_x001A_ and RV complained of burning. Caregiver was asked by home health to demonstrate cleaning of RV_x001A_s catheter and staff was unable to do so correctly. RP stated that she was unaware that the caregiver did not know how to provide appropriate catheter care for RV. Home health record dated February 27, 2014, documented that RV was not being repositioned as requested by home health. RV is unable to turn him/herself. + + + +Licensee failed to provide appropriate interventions which resulted in skin injury and unreasonable discomfort. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +HB147172B,518425,AFH,5/22/2014,"Resident #2 (RV2) required total assistance with his/her care needs as he/she was unable to move any part of his/her body and could only blink with his/her eyes. On or about December 26, 2013, RV2 stated that he/she did not feel well and wanted to go to the hospital. Witness #3 (W3) stated that he/she repeatedly told Reported Perpetrator #1 (RP1) to check on RV2. W3 also insisted to RP1 that RV2 required medical care. RP1 maintained that RV2 was fine. When RV2_x001A_s condition deteriorated further, RP1 agreed to call an ambulance. RV2 was not responsive to verbal or painful stimuli when the emergency medical personnel arrived. RV2 was transported a medical facility. Hospital records for RV2 dated December 27, 2013 indicated that RV2 had _x001A_severe sepsis_x001A_. W3 reported that RV2 was in the ICU for two weeks. + + + +Later RV2 decided to move to a different facility. RV2 indicated that the provision of services at RP1_x001A_s adult foster home became worse after RP1 learned that RV2 was going to relocate. RV2 reported that staff began to respond very slowly or not at all when he/she called for assistance. Witness #15 (W15) remembered that RP1 had told care staff that they _x001A_don_x001A_t have to rush_x001A_ when RV2 called. Witness #19 (W19) also reported that RP1 told staff to respond to other residents first and then to assist RV2. + + + +Licensee failed to provide appropriate care and services to RV2. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +HB147172A,518425,AFH,5/22/2014,"Resident #1 (RV1) required specialized tracheostomy (trach) care. On or about May 1, 2014, RV1 needed his/her trach suctioned. RV1 requested that Witness #1 (W1) provide that service. Reported Perpetrator #1 (RP1) told RV1 that he/she would have to wait approximately 20-30 minutes if RV1 wanted W1 to perform that task. RP1 began the suctioning procedure anyway. RV1 stated that the suctioning was performed in a hurried fashion which RV1 did not like. + + + +After RP1 left RV1, RV1 began crying and asked for his/her family member. RV1 reported that he/she was frustrated that his/her request for W1 to provide the care was disregarded. During the course of the investigation, Witnesses #2, #6, #11, #14 and #17 all reported that RV1 had wanted W1 to provide the trach care, not RP1. + + + +Licensee failed to respect RV1_x001A_s wishes which caused RV1 distress. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +CO14172,518425,AFH,5/12/2014,,3,400,,, +CO14175,518425,AFH,9/10/2014,#AFHNR14-008 issued / Amended #AFHNR14-008 issued / Withdrawal of #AFHNR14-008 issued. Per agreement with both parties - through counsel - matter concluded on 08/28/15.,3,0,,, +CO15047,518425,AFH,2/3/2015,"Immediate suspension #AFHSUS15-004 issued due to preliminary APS investigation, resident protection and staffing standards",3,0,,, +HB150170A,518425,AFH,2/6/2015,"Resident #1 (RV) required full assistance with mobility, toileting, eating, dressing and bathing. RV communicated his/her need for assistance by making a clicking noise with his/her teeth. RV_x001A_s Care Plan dated December 11, 2014 documented that caregivers need to listen to RV and help him/her with whatever he/she might want or need. The care plan described that RV_x001A_s night needs might include _x001A_moving pillows, re-positioning RV in bed, scratching different places on his/her body, wiping his/her face, toileting and providing water._x001A_ + + + +On or about February 6, 2015, the Department received a complaint which alleged the facility staff did not respond to RV_x001A_s requests for assistance. Witness #2 (W2) reported that he/she had heard RV making noises with his/her mouth _x001A_all night long_x001A_ to get Licensee_x001A_s attention on at least 10 occasions in the past six months and that Licensee failed to respond to RV. W2 also stated that RV had specifically told him/her that he/she was in pain and having anxiety _x001A_all night_x001A_ because the Licensee had not responded to his/her calls for assistance. When W2 asked Licensee about why she did not respond to RV, Licensee replied, _x001A_[RV] is fine. What could [RV] possibly need all the time?_x001A_ Witness #3 (W3) also reported that he/she had heard RV calling out for Licensee at night and confirmed that Licensee did not respond. W3 stated that he/she had witnessed this at least 20 but no more than 30 times in the past three years. + + + +During the course of the investigation, Licensee stated that she is always awake at night and that she can easily hear RV making noises with his/her mouth. + + + +As a result of these findings, OLRO concluded that Licensee failed to follow RV_x001A_s care plan resulting in pain and continued suffering. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +HB150170B,518425,AFH,2/6/2015,"Resident #1 (RV) had a history of chronic pain and anxiety. RV had written orders for narcotic pain and anti-anxiety medications to be dispensed on an _x001A_as needed_x001A_ (PRN) basis. On or about December 16, 2014, RV reported to Witness #1 (W1) that he/she had been in a lot of pain over the weekend of 12/14/14 and 12/15/14 and that when RV asked for pain medication, Licensee would not administer it. RV_x001A_s December 2014 Medication Administration Record (MAR) indicates that no PRN narcotic pain medication was dispensed that month. W1 reported that Licensee had argued with him/her in the past about not wanting to give an ordered narcotic pain medication. + + + +Witness #2 (W2) stated that when RV asked for his/her PRN medications, Licensee would often argue with RV and tell him/her that he/she did not need them. W2 also stated that there were times when Licensee would pretend that she had given RV the requested medication via his/her feeding tube when, in fact, she hadn_x001A_t. W2 further reported that Licensee asked him/her to also pretend to give RV his/her medications. Sometimes RV would ask to be given more medication when he/she did not find relief or ask Licensee to call his/her medical professional and tell him/her that the medications were not effective. + + + +W2 also reported that when the Licensee wrote _x001A_gave_x001A_ [a medication] in quotes, it meant that she had pretended to give RV his/her medication. W2 supplied a copy of a handwritten note and a text message which demonstrated Licensee_x001A_s usage of quotes in this manner. + + + +Additionally, during the investigation it was also discovered that the facility had run out of RV_x001A_s anti-depressant medication on or about February 19, 2015. W2 noted the missed medication dose on RV_x001A_s MAR and attached a note to Licensee with an explanation. The next day W2 noticed that his/her MAR entry had been removed and initials re-written so it now reflected a successful administration. Licensee acknowledged to W2 that she had altered RV_x001A_s record. Licensee also advised W2 to not reveal to the Department that Licensee had changed the entry. + + + +As a result of these findings, OLRO concluded that Licensee failed to administer medications as ordered which resulted in RV experiencing unnecessary suffering and failed to demonstrate good judgment and truthfulness. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +HB153487,518442,AFH,11/9/2015,"RV was admitted to the facility at approximately 7:00 p.m. on 11/06/2105, and at about 10:00 p.m. began to experience abdominal pain and was crying out. RP1 responded and began to assess RV's condition. RV's family was contacted and RV was provided with tea and music. The Department's investigation determined that RP1 also kissed RV on the forehead, called RV ""sweetheart"" and ""honey;"" called RV ""beautiful"" and massaged RV's hands. The investigation determined that RP touched RV in a manner RV considered inappropriate, including caressing RV's arms, kissing RV, touching RV under his/her shirt and fondling RV which made RV feel ""scared, mad and helpless."" RV was transported to the hospital for his/her abdominal pain and did not return to the facility. RV's reports of this incident to various incident responders were consistent, and RV has no known history of making complaints of inappropriate touching.",3,2500,Substantiated,Substantiated,Sexual abuse +MS116122,518447,AFH,1/12/2011,"Resident #1 (RV1) had a partial dental bridge. Resident #1's dental chart notes dated July 13, 2010 indicated that the partial bridge had been left in RV1's mouth for an extended period of time. Reported Perpetrator #2 (RP2) was told on July 13,2010 that Resident #1's partial bridge needed to be taken out every night. RP2 attended a dental visit on January 10, 2011 with Resident #1. Following the visit, Witness #2 stated that Resident #1's mouth had a lot of decay due to not removing his/her partial bridge. Witness #2 elaborated that Resident #1 will have to have two abscessed teeth extracted and that it appeared as though Resident #1's partial had not been removed since the dental visit six months ago. RP2 was interviewed and stated that Resident #1's partial was left in for several weeks without being removed. RP2 stated that Resident #1 was resistant to removing his/her partial bridge. Resident #1's care plan was reviewed and indicated that Resident #1's partial bridge was to be removed every night and RP2 was to brush RV1's teeth and partial each night. Reported Perpetrator #2 failed to contact Resident #1's dental professional at any time and failed to remove RV1's partial denture each night according to his/her care plan.",3,0,Not Substantiated,Substantiated,Neglect +CO12018,518447,AFH,1/13/2011,,3,150,,, +FL117259,518461,AFH,6/20/2011,"RV has severe short term memory loss and confusion. RV has a recent history of dizziness and falls while walking - the AFH had been notified of these issues prior to RV's admission. On June 20, 2001, RV was allowed to leave the AFH unaccompanied. RV became lost and was picked up by the police and eventually returned to the AFH.",2,0,,, +RD129617,518475,AFH,2/28/2012,"It was reported that on or about February 28, 2012, Licensee failed to protect Resident #1 (RV1) from financial exploitation. On February 18, 2012 RV1 received a bottle of 10 capsules of narcotic medication to be taken as needed for pain. RV1 was never administered any of the pain medication. When the bottle of pain medicati9on was counted on February 28, 2012 there were 2 capsules missing. Licensee's failures are a violation of resident rights, is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS129672,518486,AFH,4/3/2012,"On or about April 3, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate medical care to Reported Victim (RV). On April 3, 2012, it was discovered by Reported Perpetrator #2 (RP2) that RV had a fever of over 102 degrees. RP2 did not take any action or contact a medical professional after learning that RV had a fever of over 102 degrees. The licensee failed to intervene when RV's condition changed. The failure is a violation of Oregon Administrative Rule.",2,0,,, +CO13102,518486,AFH,7/10/2013,"On July 10, 2013, the licensor conducted an unannounced home visit at the licensee_x001A_s Adult Foster Home (AFH). During the visit the licensor discovered that the licensee_x001A_s criminal records check expired on 6/22/2013. The licensee submitted her criminal records application on 7/08/2013. The licensee acknowledged living in the AFH and providing care to residents alone during the night. The licensee did not have a cleared criminal records check as required. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +CO14145,518486,AFH,7/14/2014,"On July 30, 2014, the local licensing authority conducted an unannounced renewal inspection and determined that licensee's criminal background check had expired, as had the background check of one of her caregivers.",3,500,,, +CO14150,518486,AFH,7/23/2014,"Licensee did not submit a completed renewal application timely. Licensee has not completed the required continuing education credits. Licensee's criminal background check had expired, as had the background check of several caregivers as of July 10, 2013. On July 14, 2014, Licensee again had an expired criminal background check, as did one of her caregivers.",3,0,,, +CO13091,518504,AFH,7/19/2013,,3,500,,, +MV146927C,518504,AFH,3/18/2014,"It was reported that on or about March 18, 2014, Licensee failed to follow physician orders for Resident #1's (RV1) medications. RV1 was discharged from the hospital on June 14, 2013, with physician orders for 5 medications. Licensee failed to administer RV1's medications per the June 4, 2013, physician orders. Licecee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +RD118748,518563,AFH,12/6/2011,"On or about December 6, 2011, Reported Perpetrator #2 (RP2) had overslept. When transportation for Resident #1's (RV1) early morning medical appointment arrived, RV1 was still asleep. RP2 was witnessed throwing off the covers from RV1's bed, awakening him/her abruptly and placing RV1 in his/her wheelchair when RV1 was only half-dressed. The facility failed to treat RV1 with dignity and respect. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RD128896A,518563,AFH,12/16/2011,"On or about December 16, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). During a regular weekly medical examination RV was found to have a stage II pressure wound on RV's coccyx. RV was transported to the hospital for treatment on 12/15/2011. RP1 discovered the open wound at least two weeks prior to the medical visit. RP1 did not notify any medical personnel and inform them of RV's change of condition. RP1 attempted to keep RV off of h/her backside by propping h/her up with pillows while sleeping. There was no documentation of the wound. The licensee failed to assure timely medical treatment for RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +RD128896B,518563,AFH,12/16/2011,"On or about December 16, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to intervene when Reported Victim's (RV) condition changed. RV was transported to the emergency room on 11/10/11 for issues related to weakness and shakiness. During that visit RV weighed 128 pounds and it was reccomended that more protein be included in RV's diet and that RV should see a dialysis dietician. During another visit to the emergency room on 12/15/11 it was noted that RV weighed 113 pounds and required assistance with eating. RP1 was aware of RV's weight loss and poor appetite and made no attempt to consult with any medical or dietary peronnel. The licensee failed to intervene when RV's condition changed. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14029,518563,AFH,10/30/2013,"Non-compliance. Failed to satisfy licensee requirements by the time license expired; however, paper license already given to licensee. Issued warning letter",2,,,, +CO15013,518563,AFH,10/31/2014,"On December 23, 2014, the licensor issued a Notice of Violation and Correction for failure to initial Resident #4_x001A_s (R4) furosemide on his/her medication administration record (MAR) from 12/1/2014-12/23/2014. Adult protective services (APS) made a visit to the licensee_x001A_s adult foster home on 1/7/2015. During the visit APS observed R4_x001A_s MAR for the month of December, 2014. APS discovered that initials had been filled in for the month of December, 2014, for R4_x001A_s furosemide. The licensee falsified R4_x001A_s MAR.",3,250,,, +RD159817,518563,AFH,12/23/2014,"On or about December 30, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). RV's medical visit summary dated 2/13/2014 prescribed medication #1 (M1) a fluid retention medication 20mg one tablet by mouth once daily. On 12/23/2014 RV did not have a bottle of M1 and there was no documentation of M1 on RV's medication administration record for December, 2014. RV's physicians review of medication administration dated 7/9/2014 prescribed medication #2 (M2) an anti-depressant 30mg one tablet one time daily in the morning. RP did not have the bottle of M2 in the adult foster home and M2 was not documented on the medication administration record for RV. The licensee failed to provide a safe medication administration system for RV.",2,,,, +CO15106,518563,AFH,6/2/2015,"Licensee Voluntarily surrendered here license in writing effective June 5, 2015. Suspension drafted and signed but not delivered.",2,0,,, +CO15107,518563,AFH,6/2/2015,Licensee voluntarily surrendered her license in writing effective 6/5/2015. Condition was not drafted.,3,,,, +RD151384,518563,AFH,4/15/2013,"On or about May 13, 2015, APS received a complaint that the facility failed to protect RV from misappropriation of his/her property. During the course of the investigation, APS substantiated the following: prior to RV moving into RP's home, they did not know one another. RP visited RV in the hospital around January 2013, after which RV moved into RP's home. On or around the middle of April 2013, RV signed a deed giving RP 1/3 ownership of RV's home located on approximately 3.8 acres. RV did not receive any money from transferring property out of his/her name. RV wanted the property to be used as a nonprofit wildlife refuge and have RP oversee the property to ensure it operated as a nonprofit organization even though transfer of assets is a violation of OAR. Licensee's failure to use resident's property for the benfit of the resident and transferring ownership to Licensee is a violation of OAR and resident rights, is considered financial exploitation, and constitutes abuse.",4,,,,Financial abuse +BO152516,518563,AFH,5/29/2015,"On or about May 29, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to provide appropriate care to RV. During the course of the investigation, APS determined that the following occurred: RV's careplan notes that RV has limitations in bathing, toileting, dressing, mobility transfer, and personal hygiene. RV is unable to transfer or walk on his/her own and uses a wheelchair. A few days before May 29, 2015, RV slipped while toileting and fell in his/her own urine and needed assistance with cleansing and getting back up. On May 29, 2015, RV again fell while toileting, into his/her own feces, and needed assistance with cleansing and getting back up. W8, instead of a caregiver, cleansed RV and assisted RV into RV'sr own clothes. RV's hygiene was not maintained on a regular basis and most of RV's assistance came from W8 and not staff. After the fall, staff noticed substantial skin irritation, although RP2 indicated that ""we were all aware of it"". Most of RV's skin from belly, upper legs, and groins were covered in broken red skin that was oozing liquid. RV was admitted to the hospital where RV presented with fungal infection on RV's feet and labwork also indicated significant dehydration. RP2 was aware of RV's skin condition and RP2's failure to provide appropriate care is a violation of resident rights, is considered neglect, and constitutes abuse. The facility's failure is considered a violation of OAR and resident rights and is also considered neglect, constituting abuse.",4,,Substantiated,Substantiated,Neglect +GP129964A,518591,AFH,5/3/2012,"On or about May 3, 2012, it was alleged that Reported Perpetrator failed to provide appropriate service to Reported Victim (RV). It was determined that on or about December 10, 2011, RV was found in RV's bedroom wedged between two beds. RV was found to be wet and soiled and feces was discovered on the floor. RV's care plan states that RV does not have bladder control and has limited bowel control. The care plan notes that RV urinates mostly at night and caregivers are instructed to use an intercom to monitor RV at night. RV requires a Hoyer lift to wheelchair for mobility. The licensee failed to provide appropriate care to RV resulting in unreasonable discomfort for RV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +GP120454,518591,AFH,7/9/2012,"On or about July 9, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from verbal abuse. It was determined through interviews that RP spoke to RV inappropriately. The licensee failed to protect RV from loss of dignity. The failure is a violation of Oregon Administrative Rule.",2,0,,, +GP120711,518591,AFH,8/3/2012,"On or about August 3, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from financial exploitation. RV transferred to another facility. RP did not give RV h/h narcotic pain medication to be transferred with RV. It was determined that the licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights, is considered financial exploitation, and constitutes abuse.",2,0,,,Financial abuse +ES092530,518636,AFH,6/1/2009,,1,0,,, +CO14207,518636,AFH,9/24/2014,,3,400,,, +ES147379,518637,AFH,6/8/2014,"On or about June 12, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). On 6/8/2014 RV was administered a double dose of Medication #2 (M2) for the morning and midday doses. The medication administration record (MAR) for the month of June for RV shows that M2 was not inititialed as being administered at noon on 6/6 or all three doses on 6/7. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD117590C,518701,AFH,7/1/2011,"On or about July 7, 2011, a report was received stating that Licensee's staff had failed to respond timely to Resident #1's (RV1) calls for help after RV1 experienced a non-injury fall on June 14, 2011. The investigation concluded that wrongdoing on the part of the Licensee was substantiated.",1,0,,, +NB117820A,518707,AFH,8/9/2011,"On or about August 9, 2011, it was reported that the Licensee had failed to provide appropriate care to Resident #1 (RV1). As concluded in a home evaluation report dated June 28, 2011, an alternating air pressure mattress was ordered for RV1 on June 29, 2011. The item was received at the facility on or about July 5, 2011. It had been determined through interviews that the mattress had still not been placed on RV1's bed as of August 9, 2011. The investigation concluded that Licensee's failure to carry out treatment orders was substantiated.",1,0,,, +NB117820B,518707,AFH,8/9/2011,"On or about August 9, 2011, it was reported that the Licensee had failed to maintain a safe medication administration system. The investigation concluded that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +NB118248,518707,AFH,10/1/2011,"It was reported that on or about October 17, 2011, Licensee failed to provide a safe medication administration system. Licensee gave as needed (PRN) medications to Resident #1, Resident #2, and Resident #3 on a scheduled basis instead of administering the medication as prescribed. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO14141,518707,AFH,7/29/2014,Unqualified caregiver,3,200,,, +RD120618A,518708,AFH,6/2/2012,"Resident #1 had prescriptions for multiple medications. On April 12, 2012, an order for a PRN (as needed) Medication #1 was written. The April 2012 Medication Administration Record (MAR) for Resident #1 was reviewed. The April 2012 MAR reflected that Medication #1 had been given four times each day beginning April 1 through April 11, 2012 which was prior to the date the order was written. The April 2012 MAR had entries initialed by both Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2). The licensee provided no explanation for why the MAR was initialed between April 1 and April 11 and could not confirm whether Medication #1 had actually been given on those days. Also, the documentation did not include why the medication was given or the result. + + + +Resident #1 had a PRN order for Medication #2. Resident #1's April 2012 MAR indicated that Medication #2 had been administered every day between April 1 and April 20, 2012 by either RP1 or RP2. However, the time and reason it was given and the result was not documented. + + + +Resident #1 also had an order written on March 23, 2012 that specified his/her blood sugars were to be checked every Monday. During the investigation, the licensee indicated that Resident #1's medical professional reiterated this order on April 20, 2012. A physician's order dated May 10, 2012 also referred to the CBGs being checked one time per week. No records from March 2012 or April 2012 indicated these orders were followed. Resident #1's MAR for May 2012 noted that the blood sugars were checked three times per day between May 1 and May 21, 2012 which was more frequent than ordered. However, the results were not recorded. The investigation concluded that the facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RD120618B,518708,AFH,6/2/2012,"Resident #1 (RV1) experienced an unobserved fall in his/her bedroom on or about May 3, 2012. The fall resulted in facial injuries as evidenced by black and purple marks around both eyes. On or about May 15, 2012, RV1 had another fall in his/her bedroom during which RV1 hit his/her head. There were no witnesses to this second fall. Reported Perpetrator #1 (RP1) failed to notify RV1's physician and family regarding either fall or obtain evaluation of injuries. RV1's progress notes dated May 21, 2012 refer to RV1 being a ""high fall risk""; however, the care plan for RV1 was not updated to reflect RV1's increased risk of falls or have possible interventions identified and in place. Facility failed to address RV1's change in condition. The failure is a violation of Oregon Administrative Rule.",2,0,,,Neglect +RD120618C,518708,AFH,6/2/2012,"On or about May 2012, Resident #1 was observed sitting in a wheelchair with a belt wrapped around him/her. The belt was tied in the back where Resident #1 was unable to untie it. Reported Perpetrator #2 was working alone that day. When the licensee returned to the AFH and found the belt being used as a restraint, the licensee untied Resident #1 and questioned Reported Perpetrator #2 about its use. Reported Perpetrator #2 responded that Resident #1 kept getting up without assistance so Reported Perpetrator #2 tied Resident #1 in the chair so Reported Perpetrator #2 could vacuum the house which required him/her to be away from the room where Resident #1 was seated. The licensee informed Reported Perpetrator #2 that he/she could not restrain Resident #1. The restraint was used for the convenience of Reported Perpetrator #2. The facility failed to provide a safe environment for Resident #1.",3,0,Not Substantiated,Substantiated,Restraints +RD120618D,518708,AFH,6/2/2012,"On or about June 7, 2012, the Department received a complaint that alleged the facility had failed to timely assess and intervene when Resident #1 (RV) experienced a change in condition. During the course of the investigation, Licensee (RP1) reported that RV had experienced an increase in behaviors between March 2012 and June 2012. RP1 stated that she had contacted RV_x001A_s Contract RN (CRN) and RV_x001A_s medical professional who directed medication adjustments. RV_x001A_s physician documented visits with RV on March 9, 2012, April 12, 2012, May 10, 2012, May 24, 2012 and May 31, 2012. + + + +On May 24, 2012, RV_x001A_s medical professional ordered a blood draw and urine sample for analysis. These lab tests were not conducted. On May 31, 2012, the physician issued a second order for a blood draw due to a suspected urinary tract infection and potential GI bleed. RP1 stated the labs were drawn on May 31, 2012. + + + +On June 2, 2012, RV displayed an altered mental status and had drank or eaten very little during the previous four days. RV was taken to a medical facility where RV was diagnosed with a urinary tract infection. RP1 acknowledged that she had waited for the lab results before pursuing further action. + + + +The facility failed to follow written orders in a timely manner which resulted in a delay in treatment. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,0,,,Neglect +ES132229,518776,AFH,1/24/2013,"On or about January 24, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). It was determined that the licensee would take RV to the local church for meals. At least one time RV expressed that RV did not want to go. RP knew RV had expressed that h/she did not want to join the outing. On one occasion RV was encouraged to go to the church. During the walk from the church to RP's vehicle RV slipped and fell. RV did not sustain any injury. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO15165,518794,AFH,8/18/2015,,3,450,,, +HM147383,518823,AFH,6/2/2014,"It was reported that on or about June 2, 2014, Licensee failed to provide a safe envioronment for Resident #1 (RV1). Reported Perpetrator #2 (RP2) became upset with RV1, cussed at RV1 and called him/her names. Licensee's failures are a violation of Oregon Administrative Rules. RP2's failures are considerd verbal/mental abuse. Wrongdoing on the Licensee has been substantiated and abuse has been apportioned to RP2.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HM148649A,518823,AFH,7/31/2014,"It was reported that on or about July 31, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee would take RV1's shoes and wheel chair from RV1 to prevent RV1 from wondering out of his/her room. RV1 thinks his/her is being locked at night. RV1's bedroom door was observed to have a locking mechanism on the outside of the door. Licensee's failures are considered involuntary seclusion and constitute abuse. Wrongdoing on the part of the Licensee is substantiated.",2,,,,Involuntary Seclusion +HM148649C,518823,AFH,7/31/2014,"It was reported that on or about July 31, 2014, Licensee failed to maintain an adequate medication administrative system for Resident #1 (RV1). Licensee failed to ensure Resident #1 receivied his/her ordered medication from July 28, 2014, through July 31, 2014. Licensee failed to have a medication administration record (MAR) and failed to have as needed (PRN) peramateres. Licensee's failures are a violation oF Adult Foster Home (AFH) Oregon Administrative Rules (OARs). Wrongoing on the part of the Licensee was substantiated.",2,,,, +HM148649B,518823,AFH,7/31/2014,"It was reported that on or about July 31, 2014, Licensee failed to follow Resident #1's care plan. Licensee had night needs according to the care plan provided by the previous facility in which Resident #1 resided. Licensee dis not always assist Resident #1 with his/her night needs with toileting and cleaning. Licensee failed to have a care plan for Resident #1. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO11084,518867,AFH,1/10/2011,"Licensee has repeatedly demonstrated substantial non-compliance with the rules and regulations that are applicable to the health and safety of caring for residents of an adult foster home. Licensee_x001A_s failures have resulted in harm to residents and exhibited the potential for serious harm. These failures demonstrate the Licensee failed to exercise reasonable precautions to protect residents from any threat of harm to their health, safety or well-being.",4,0,,,Neglect +MM148480C,518874,AFH,9/2/2014,"It was reported that on or about September 2, 2014, Licensee failed to provide Resident #1 with and adequate medication administration system. Resident #1 had physician orders to receive a medication daily at 8:00 AM. On September 14, 2014, Resident #1 was not given the physician ordered medication as required. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MM148480A,518874,AFH,9/2/2014,"On September 2, 2014, Resident Victim #1 (RV1) was being transported by Reported Perpetrator #3 (RP3) to a medical appointment via a facility vehicle. RV1 was sitting in his/her medical devise while being transported to his/her appointment. RP3 failed to ensure RV1 was wearing the appropriate safety belts and failed to ensure RV1 was properly secured during transport. During transport RP3 was cut off in traffic and was forced to apply the brakes resulting in RV1 falling out of his/her medical device, sustaining two broken knees and being transported to the hospital. Licensee and RP3_x001A_s failures are considered a violation of Adult Foster Home (AFH) Oregon Administrative Rules (OARs) is considered neglect and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +RB133115,518875,AFH,4/27/2013,"It was reported that on or about April 27, 2013, Licensee failed to provide appropriate care for Resident #1 (RV1). Progress no November 18, 2012 - May 1, 2013, indicates RV1 had a significant change in his/her health condition and wasn't getting the necessary care and services he/she needed at the Adult Foster Home (AFH). Licensee failed to update RV1's care plan as his/her condition changed. Licensee's failures are a vilation of AFH Oregon Administrative Rules (OARs), is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +MV135219,518889,AFH,11/20/2013,"On or about November 27, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4) and Reported Victim #5 (RV5). RP's utilities have been shut off multiple times due to lack of payment. RV2 has expressed his/her frustration due to the utilities being shut off. Caregivers use RV's cell phones to order RV's prescription medications because caregivers do not have the ability to call long distance at the adult foster home (AFH). The licensee failed to provide a safe environment for RV's. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV135402A,518889,AFH,12/13/2013,"On or about December 16, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4) and Reported Victim #5 (RV5). On multiple occasions Reported Perpetrator #2 (RP2) did not order RV's medications on time. On at least one occasion RV1 went three days without his/her anti-anxiety medication because the medication was not available in the home. Witness #2 (W2) and RP1 acknowledged on at least one occasion RP2 was late ordering the medication which resulted in RV's missing ""one pill"" of medication. The licensee failed to provide a safe medication administration system for RV's. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV135402B,518889,AFH,12/13/2013,"On or about December 16, 2013, it was alleged that Reported Perpetrator #1 (RP1) frailed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4) and Reported Victim #5 (RV5) from inappropriate verbal comments. RV's stated that Reported Perpetrator #2 (RP2) would yell and use profanity toward RV's. RV2 ""couldn't handle it"" and would go into his/her room and shut the door. On one occasion RP2 was observed yelling and cursing toward RV5.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MV147004,518889,AFH,5/6/2014,"On or about May 7, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate sexual contact. On multiple occasions Reported Perpetrator #2 (RP2) made inappropriate sexual comments to RV and unzipped his/her pants and exposed his/her genitals to RV. On one occasion RV woke up to find RP2 lying naked in bed next him/her touching his/her breast. RV disclosed to Witness #2 (W2) that RP2 had made inappropriate sexual comments toward RV. W2 reported the behavior to RP1. RP1 moved RP2 to another one of RP1's adult foster homes where a separate allegation of inappropriate sexual contact by RP2 was substantiated. RP1 did not report the incident to the appropriate investigative authority as required. RP2 was arrested for sexual assualt on 6/3/2014. The licensee failed to provide a safe environment for RV. The Failure is a violation of resident rights and constitutes abuse.",4,,Substantiated,Substantiated,Sexual abuse +CO16037,518909,AFH,2/17/2016,,4,0,,,Neglect +GP164676,518909,AFH,2/17/2016,,4,2500,Substantiated,Substantiated,Neglect +CO15203,518911,AFH,9/28/2015,For failure to have a qualified caregiver on duty 24 hours per day in the AFH.,3,250,,, +GP118183,518947,AFH,10/10/2011,"On or about October 11, 2011, a complaint was received alleging that Licensee (RP) had failed to provide appropriate wound care. The investigation began the same day. It was determined that when RV1's medical professional called RP in September, 2011 to schedule an office visit with RV1, RP refused. On or about October 15, 2011, RV1 was admitted to the hospital. Emergency room staff noted that RV1 was not responding when people talked to RV1. Staff identified a wound two to three inches in diameter, dark red in color. Through interviews and observations, it was determined that RP did not have the training to treat Resident #1's (RV1) skin ulcers and had failed to seek additional assistance. Wrongdoing on the part of the Licensee was substantiated.",3,0,,, +CO15206,518959,AFH,9/29/2015,"On July 6, 2015, the local licensing authority (_x001A_LLA_x001A_) conducted the annual re-licensure inspection at Licensee_x001A_s, Beth Bailey(_x001A_Bailey_x001A_) Adult Foster Home (_x001A_AFH_x001A_). During the course of the inspection the LLA determined that Licensee, Bailey had allowed three substitute caregivers, Vivencia Millan (_x001A_Millan_x001A_), Zenaida Jacinto (_x001A_Jacinto_x001A_) and Clorissa Esstale Ludwig (_x001A_Ludwig_x001A_), to work in the AFH as unqualified caregivers because there was no record of completion of the Department_x001A_s Caregiver Workbook.",3,450,Substantiated,, +BH159991,518979,AFH,1/7/2015,"On or about January 8, 2015, APS received a complaint that RP failed to provide a safe and secure environment. During the course of the investigation, APS substantiated that RV has a history of wandering, which was noted in the assessment RP did prior to admitting RV into the facility and is also noted in RV's care plan. RV previously wandered from the facility August 28, 2014 and again on January 7, 2015. Although RP took steps to reduce risks of elopement, such as signs on doors, a bracelet for RV, and alarms on facility door's, RP did not alarm the side door of the garage. RP exited the facility through the side door of the garage and was found in a neighbor's home. RP was the only caregiver in the home at the time, and was providing care to another resident when RP noticed that RV was not in the facility. RV was at risk of harm by wandering from the facility. Facility's failure to alarm all doors or have additional staff is a violation of resident's rights, is considered neglect, and constitutes abuse.",3,300,,,Neglect +BH149023,518979,AFH,8/29/2014,"On or about September 10, 2014, APS received an allegation that the facility did not provide a safe environment for the RV. During the course of the investigation, APS substantiated the following: On or about August 29, 2014, RV wandered away from the facility and police were called to locate RV. Three hours after it was first noticed RV was missing, RV was located seated in a neighbor's car. RV had a history of exit seeking and had left the facility unattended at least once prior to this incident. The RV's care plan did not adequately address the RV's wandering behavior and the care plan was not updated after RV left the facility the first time in July 2014. RV was able to leave the facility unattended because the door was accidentally left open. The facility's actions are a violation of resident rights, are considered neglect, and constitute abuse.",2,,Substantiated,Substantiated,Neglect +TM134733,519050,AFH,10/13/2013,"On or about October 16, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from misappropriation of RV's medication. On 10/6/2013 RV received a new pain medication prescription for 120 tablets. On 10/10/2013 Witness #1 (W1) did a medication count and discovered that 15 pain medication tablets were missing. Witness #3 (W3), Witness #4 (W4) and Witness #5 (W5) had been responsible for administering medication to RV between 10/6/2013 and 10/10/2013. W3, W4 and W5 denied taking any pain medication from RV. RP denied taking RV's pain medication. RP reported the incident to law enforcement. RP implemented a new medication administration system in order to help prevent the theft of medications. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV132647,519062,AFH,3/13/2013,"On or about March 13, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV's physician order from 1/14/13 state that RP was to test RV's blood sugar twice daily. RP acknowledges that h/she does not test RV's blood sugar. RP also acknowledged that h/she administers a stool softener to RV without any physician orders. It was determined that the licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rule.",2,0,,, +HB118653,519081,AFH,12/7/2011,Resident #1 (RV1) was dispensed 10 times the amount of his/her Medication #1. Reported Perpetrator #2 (RP2) immediately called 911 to report the accidental overdose. RV1 was taken to the hospital for observation. Facility failure to administer the correct dosage of Medication #1 placed RV1 at risk of serious harm. The failure is a violation of Oregon Administrative Rule.,3,150,,, +BA151507,519800,AFH,6/2/2015,"It was reported that on or about June 2, 2015, Licensee failed to provide a safe environment for Resident #1 and Resident #2. Licensee made inappropriate comments to Resident #2 that resulted in Resident #2 feeling belittled. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated, +MV105873,519833,AFH,7/26/2010,"On or about November 5, 2010, it was reported that the Licensee failed to provide a safe medication administration system. On or about May 2009, Licensee administered expired medications to Resident #1 (RV1) and failed to implement physician orders as perscribed. Interviews and Oservations concluded that wrongdoing on the part of the licensee was substantiated.",2,0,,, +CO11017,519950,AFH,12/23/2010,,2,250,,, +CO12015,519950,AFH,2/13/2012,Update 4/9/2013: AFH closed on 7/2012.,3,0,,, +KF129220,519950,AFH,2/4/2012,"On or about February 4, 2012, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide a safe medication administration system for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4) and Reported Victim #5 (RV5). It was determined that pain medications were missing or replaced with over-the-counter medication for RV1, RV2, RV3 and RV4. RP2 admitted to taking the pain medication from RV1, RV2, RV3 and RV4. RP2 was not administering medications as ordered to RV1, RV2, RV3, RV4 and RV5. The licensee failed to provide a safe medication administration system resulting in medications being stolen, and RV1, RV2, RV3, RV4 and RV5 not receiving their prescribed medication. The failures are a violation of resident rights and constitutes abuse.",3,0,,,Financial abuse +BA134563,519971,AFH,5/18/2013,"It was reported that on or about May 18, 2013, License failed to protect Resident #1 and Resident #2 from mental/emotional abuse. Between February 2013 and May 2013 Reported Perpetrator #2 (RP2) yelled, intimidated and threatened Resident #1 and Resident #2. Licensee's failures are a violation of Oregon Administrative Rules and RP2 actions constitute verbal/emotional abuse. Wrongdoing on the part of the Licensee is substantiated.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +BA147101,519971,AFH,3/12/2014,"RV receives long acting insulin 14 units at 9pm daily and short acting insulin 100 ml per unit sliding scale at 8am, 1pm, and 5pm. RP2 was delegated to give insulin. On 3/12/14 at 8:00pm, RP2 administered 14 units of short acting insulin instead of 14 units of long acting insulin. After the incident occurred appropriate steps were taken to care for RV and prevent a further incident from occurring.",2,,,,Neglect +BA149481A,519971,AFH,10/26/2014,"On or about October 29, 2014, Adult Protective Services (APS) received a complaint that RPs failed to maintain a safe and secure environment. During the course of the investigation, APS substantiated the following: multiple residents have been yelled at in RP1's adult foster home. Both RP1 and RP2 have yelled at residents. Residents have suffered emotional harm, in the form of fear, unreasonable discomfort, and/or loss of personal dignity, due to RP1's and RP2's actions. RP1 failed to provide a safe environment for residents. RP1's actions are a violation of resident rights and constitute verbal abuse.",3,450,Substantiated,Substantiated,Verbal/Mental abuse +CO15115,519971,AFH,6/17/2015,LLA requsted denial of initial application for new AFH based upon: 1. repeated instances of abuse 2. submitting untrue information to the department and 3. failure to follow a final order,3,,,, +BA151407,519971,AFH,5/5/2015,"It was reported that on or aboutMay 5, 2015, Licensee failed to provide adequate care for Resident Victim #1. Licensee failures are a violation or Oregon Administrative Rules, are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee has been substantiated.",3,,,, +BA151802A,519971,AFH,6/30/2015,"On or about June 30, 2015, Adult Protective Services (APS) received a complaint that the facility failed to appropriately medicate RV. During the course of the investigation, APS substantiated the following: RV was a resident of RP1's adult foster home from October 5, 2015 through June 29, 2015. While at RP1''s facility, RV was prescribed Narcotic 1 and Narcotic 2 daily for pain, with an additional prescription of Narcotic 1 PRN for increased pain. RV stated that he/she rarely received PRN pain medication at the facility, even when asked for. Narcotic 1 was filled on April 14, 2015, for 60 pills. When the new facility received the medication, 60 pills remained in Narcotic 1's bottle. RV was given Narcotic 2 daily during June but no administration of Narcotic 1 was noted. RP1's actions were a violation of Oregon Administrative Rule. RP2's actions are a violation of resident rights, are considered neglect, and constitute abuse.",3,500,Substantiated,Substantiated,Neglect +AL121122B,520000,AFH,5/1/2012,"Resident #1 (RV1) had a previous injury that required that he/she be lifted without using his/her right arm as leverage during lifts or transfers. Reported Perpetrator #2 (RP2) had been instructed various times by several different people that Resident #1_x001A_s (RV1) right arm could not be used as leverage when lifting or transferring RV1. On or about May 9, 2012, RP2 acknowledged that he/she had lifted RV1 using RV1_x001A_s right arm as leverage. RP2 lifted and/or transferred RV1 improperly over an extended period of time despite having knowledge that this was not the proper way to provide care to RV1. Licensee was aware of RP2_x001A_s practice and coached RP2 on the proper technique. RP2 continued to work with RV1 despite continued reports to Licensee that RP2 was not using proper technique. Licensee_x001A_s failure to ensure RV1 was properly lifted and transferred was not accidental and caused pain for RV1. This failure is a violation of resident rights and constitutes physical abuse.",3,0,Substantiated,Substantiated,Physical Abuse +AL121731,520000,AFH,7/27/2012,"It was reported that on or about July 27, 2012, Licensee failed to use an assistive device properly. On July 27, 2012, Resident #1 had a ground level fall at aproximately 1:45 PM, while attempting to self tranfer. Reported Perpetrator #2 (RP2) attempted to lift Resident #1 from the floor by his/herself and was unsuccessful. RP2 then attached a gait belt to Resident #1 and attempted to lift Resident #1 from the floor but was again unsuccesseful. RP2 failed to use the gate belt in an appropriate manner, placing Resident #1 at risk of harm. Licensee's failures are a violation or Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +AL147039,520000,AFH,11/26/2013,"Resident #1 stated that he/she required assistance during the night hours. Resident #1 reported that Reported Perpetrator #2 appeared frustrated by the number of times Resident #1 requested assistance each evening. A review of Resident #1's Screening Assessment dated May 10, 2013 documented that Resident #1 ""requires assistance at night"". It is further noted that the box on the form that indicated ""provider and all caregivers are willing and able to meet the resident's care needs"" is checked. Resident #1's care plan dated May 31, 2013 also documents that Resident #1 required full assistance at night for toileting and incontinence care needs and bowel movements. Resident Chart Notes dated November 11, 2013 and November 14, 2013 indicate that Resident #1 is unable to help with his/her own transfers and that transferring Resident #1 into his/her recliner has become a two person assist. Resident Chart Notes dated November 14, 2013 stated that the facility ""has only one staff at a time"". Licensee failed to have sufficient staff needed to ensure safe provision of appropriate care and services to Resident #1. Licensee's failure is a violation of Oregon Administrative Rule.",2,,,, +AL152092,520000,AFH,9/16/2014,"It was reported that on or about September 16, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee had placed a transfer pole next to RV1's bed but it had not yet been secured to the floor or ceiling. RV1 reached for the pole to assist him/herself out of bed and the pole hit RV1 in the head causing bruising. Licensee's failure is a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +CO11056,520001,AFH,12/22/2010,,0,100,,, +SV116100,520001,AFH,1/3/2011,"In January 2011 RP1 was reported to have little food for the residents. On 01/03/11 RV1 had to call his/her family to come and get dinner for the residents. In an interview on 01/10/11 W1 confirmed that there was no food for the residents on 01/03/11, and that there is often little food for the residents. RP1 failed to provide an adequate amount of food to his/her residents on 01/03/11.",2,0,,, +SV117525A,520001,AFH,7/22/2011,"On or about July 22, 2011, it was reported that Resident #1 (RV1) was not dispensed an ordered pain medication between July 13, 2011 and July 16, 2011. RV1_x001A_s medication was not available in the adult foster home. RV1 experienced pain as a result of not having RV1_x001A_s pain medication available.",2,0,,,Neglect +SV117525B,520001,AFH,7/22/2011,"Resident #1_x001A_s (RV1) medical professional had authorized padded side rails for RV1_x001A_s safety on March 29, 2011. On July 17, 2011, staff at Licensee_x001A_s adult foster home found skin discolorations on RV1_x001A_s right hand. On July 22, 2011, staff identified a discolored area on RV1_x001A_s left hand. Injuries on both hands may have been caused by RV1 flailing RV1_x001A_s arms against bed rails. Unpadded side rails were observed in use on July 26, 2011. Licensee failure to carry out orders as prescribed was substantiated.",2,0,,, +MV132562A,520001,AFH,3/5/2013,"On or about March 5, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to administer medication as ordered to Reported Victim (RV). RV was prescribed an anti-anxiety medication by h/her primary physician. On 9/20/2012 the count of tablet left was 77. From 9/20/2012 to 2/28/2013, RV was administered 49 tablets. There are no records to indicate what happened to the remaining 28 tablets. No refills were requested during that time frame. It was also discovered that RV took h/her last dosage of the anti-anxiety medication on 2/28/2013. Reported Perpetrator #2 (RP2) did not request a refill of the anti-anxiety medication until 3/1/2013. As a result, RV was transported to the hospital on 3/4/2013 and was treated for palpitations with anti-anxiety medication. The licensee failed to administer medication as ordered to RV. The failure is violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +MV132562B,520001,AFH,3/5/2013,"On or about March 5, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate diet for Reported Victim (RV). RP1 stated that Home Health did a swallowing test on RV and did not find any signs of RV having difficulty swallowing. RP1 continued to say that there was no special diet order for RV. On July 12, 2012, a speech pathologist (SLP) made a visit to RV at the licensee's adult foster home. The SLP recommended a mechanical soft diet texture and nectar thick liquid. RV's progress notes on July 19, 2012, state that RV was being served ""dry food"", drinking regular liquids, and doesn't need powder on drinks. It was determined that the licensee failed to provide RV with an appropriate diet. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14092,520005,AFH,4/28/2014,"On April 28, 2014, the local licensing authority conducted an unannounced re-licensure inspection at licensee_x001A_s adult foster home (AFH). During the visit the licensor observed that the battery had been removed from the smoke alarm in the hallway between bedrooms. Licensee failed to maintain all required smoke alarms in working order. Licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +DA120105,520016,AFH,4/16/2012,"On or about April 16, 2012, RV noticed that money was missing from his/her bank account. RV suspected Reported Perpetrator #2 (RP2). RV gave RP2 his/her personal identification number for his/her debit card. Reported Perpetrator #1 (RP1) and RV placed $80 in RV_x001A_s wallet in his/her bedroom on 4/16/12. On 4/16/12 RP2 was cleaning RV_x001A_s bedroom. RP1 discovered that RP2 had $40 of RV_x001A_s money in RP2_x001A_s pocket. RP2 insisted that he/she was going to return the $40 to RV. RP2_x001A_s employment was terminated. + + + +Law enforcement was contacted and it was discovered that approximately $3580.00 had been withdrawn from RV_x001A_s bank account from December 2011, to April 2012. RP2 acknowledged to law enforcement to withdrawing money from RV_x001A_s bank account without RV_x001A_s knowledge or permission. Facility failed to provide a safe environment. Licensee's failure is a violation of Oregon Administrative Rule.",3,0,,,Financial abuse +DA133552B,520016,AFH,5/15/2013,"On or about May 15, 2013, it was alleged that Reported Perpetrator (RP) failed to assure resident rights for Reported Victim (RV). RV repeatedly expressed worry and concern about a perceived licensing issue told to RV by RP. The licensee failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +DA147778,520016,AFH,7/16/2014,"It was reported that on or about July 16, 2014, Licensee failed to provide safe and sanitary condition for Resident #1 (RV1). Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +DA135469,520016,AFH,12/22/2013,"On or around December 23, 2013, APS received an allegation that RP1 failed to provide care to RV. RV had a fall with injury on December 20, 2013, resulting in spinal compression fractures. RP1 did not notify medical professionals until December 22, 2013. RP1's failure to notify medical professionals at the time of injury is considered neglect and constitutes abuse. ISSUED A FOD AND E-MAILED KATIE HOWE.",3,400,,,Neglect +DA148306,520016,AFH,8/28/2014,"On or around August 28, 2014, Adult Protective Services (APS) received a complaint that the facility failed to provide proper care to the reported victim (RV), which resulted in hospitalization. During the course of the investigation, APS determined that RV had an order to be weighed daily by the facility and that any weight gain of three or more pounds were to be reported to the RV's primary doctor, as this equated to an aggravation of RV's heart issue. RV did have a weight gain of 3 lbs from August 20, 2014 to August 21, 2014, with an additional pound gain over the following day. This weight gain was not reported to the doctor and RV was taken to the hospital as a result of edema and shortness of breath. The facility failed to follow medical orders, which failure is considered neglect and constitutes abuse.",3,200,,,Neglect +MS120329A,520048,AFH,6/20/2012,"On June 20, 2012, it was reported that Licensee failed to provide appropriate care to Resident #1. Resident #1 went to the doctor on June 20, 2012. While at the doctors office Resident #1 was found to be infested with headlice and found to be in dirty un-kept condition. Resident #1 was not bathed twice a week as care planed. Licensee's failures are a violation of Oregon Administrative Rules, are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +MS120329C,520048,AFH,6/20/2012,"It was reported that on or about June 20, 2012, Licensee failed to protect Resident #1 from inappropriate verbal treatment. Facility staff would become upset with Resident #1 and raise their voices. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +ES150550,520067,AFH,3/2/2015,"On or about March 11, 2015, APS received a complaint that the facility failed to protect a resident (RV1) from a wrongful taking. During the course of the investigation, APS substantiated the following: A $25.00 Walmart gift card was mailed to RV1 from S&DS. The gift card was used by Witness 2, who is a family member of the provider. RV1 did not give permission to Witness 2 to use the gift card. Witness 2 admits to stealing items from RV1. Facility's failure to protect the resident from financial exploitation is a violation of resident rights, is considered financial exploitation, and constitutes abuse.",2,,,,Financial abuse +CO14035,520082,AFH,1/21/2014,"Resident manager (RM) Keith Lowell's (KL) background check expired on January 10, 2014. RM KL continued to live in and work in the home from January 10, 2014 until January 15, 2014, providing care to resident's unsupervised. UPDATE: FOP sent 7/30/14",3,250,,, +GP164749,520082,AFH,2/24/2016,"Resident #1 (RV1) was dependent on Licensee and caregivers for activities of daily living including bathing and personal hygiene while residing in Licensee_x001A_s AFH. Facility progress notes from 11/27/15, through 02/12/16, state RV1 received 3 showers, 5 bed baths, and 2 clean ups while in Licensee_x001A_s AFH. During this time RV1 had bowel incontinence and would smear and play in his her feces. RV1 did have skin breakdown on his/her backside due to constant wetness from incontinence. Witness #1 (W1) and Witness #3 (W3) Reported RV1_x001A_s fingernails were 2 inches long, yellow in color and had brown matter under his/her nails. Progress notes dated 12/24/15, stated RV1 refused nail care. Progress notes dates 11/10/15, and 01/10/16, indicated RV1 refused showers. + + + +On 2/12/16, RV1 was moved to another AFH and upon arrival was found to have hair matts so thick that W3 had to cut the hair matts out. Additionally it was discovered that RV1 had white _x001A_moist curd_x001A_ between his/her toes that took W3 3 days to rid of. After being moved to the new AFH RV1 was showered within 30 minutes of arriving. RV1 didn_x001A_t argued or resist showering, fingernail care, and as of 3/14/16 RV1 had only 2 bowel accidents. Licensee_x001A_s and Reported Perpetrator #2_x001A_s failure to provide basic care and services necessary to ensure the health safety and well-being of RV1 is considered neglect and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +HB105548,520123,AFH,10/26/2010,,2,0,,, +HB116099,520123,AFH,1/10/2011,,2,0,,, +CO11042,520123,AFH,4/8/2011,Condition not renewed in 2012,3,0,,, +HB121917A,520123,AFH,12/17/2012,"It was reported that on or about December 17, 2012, Licensee failed to protect Resident #1 from theft of medications. On December 17, 2012, Reported perpetrator #2 (RP2) took the key to the medication cabinet. RP2 went into the garage where the medication cabinet was located and removed three narcotic pain patches belonging to Resident #1. Licensee's failures are a violation of Oregon Administrative Rules, are considered financial exploitation and constitute abuse.",3,0,,,Financial abuse +CO15042,520157,AFH,2/23/2015,,3,250,,, +SV116185,520161,AFH,12/17/2010,,3,0,,,Financial abuse +CO11073,520161,AFH,5/24/2011,Failure to provide a safe environment and failure to have a safe medication administration system,2,850,,, +SV116185A,520161,AFH,12/17/2010,"It was reported that on or about December 2010, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee failed to ensure RV1 made it to his/her medical appointment and failed to take any action to follow up with RV1's physician after missing appointment. As a result, RV1 lost his/her primary care provider and did not have his/her health monitored as frequently as it should have been. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +SV116185B,520161,AFH,12/17/2010,"It was reported that on or about December 2010, Licensee failed to properly manage Resident #1's (RV1) monies. RV1's personal funds have been used to purchase food for general consumption at Licensee's Adult Foster Home more than once. RV1 also paid for gas and lunch for Reported Perpetrator #2 (RP2) and another resident while on an outing. Licensee's failures are a violation of resident rights and constitute financial abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +SV120055,520161,AFH,5/14/2012,"On or about May 15. 2012, it was reported that Licensee failed to provide appropriate care to Resident #1(RV1). On May 15, 2012, RV1 has an episode of weakness and was unable to get up from bed. Facility staff called to have emergency medical technicians assist with RV1 and it was decided that RV1 should be transported to the hospital. Upon arrival at the hospital staff determined that RV1 was suffering from poor hygiene and general weakness. Licensee's failures are a violation of resident right. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV133399,520161,AFH,6/3/2013,"It was reported that on or about June 3, 2013, Licensee failed to provide a safe environment for Resident #2 (RV2). Licensee took all the residents on an outing. When Licensee was ready to go back the Adult Foster Home (AFH) he/she was unable to locate RV2 so he/she left RV2 and took the other residents back to the AFH. Witness #1 (W1) saw RV2 walking and picked him/her up and returned RV2 to the AFH. Licensee's failures are a violation of AFH Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee is substantiated.",2,,,,Neglect +CO14177,520161,AFH,9/10/2014,"LLA request for civil penalty was based primarily on unqual cgs and medication system violations. However, the violations/narratives do not clearly state any cg(s) were left ""alone"". Medication violations are not mandatory. No sanction issued d/t: license suspended on 09/29/14 and Betsy, licensor, received a fax from provider dated 10/10/14 that indicated provider was ""retiring"". Home closed under sanction. No request for administrative review was received from the provider. LLA request denied.",3,,,, +CO14176,520161,AFH,9/9/2014,Licensee failed to conduct a screening and assessment. Licensee failed to prepare and document a care plan within 14-days of admission.,3,250,,, +MV147946,520161,AFH,7/9/2014,"Resident #1 (RV1) had a medical condition which required a skin care regimen. RV1_x001A_s feet were to be washed and lotion applied on a daily basis. RV1 also required assistance with general bathing. A Medical Visit Report dated July 10, 2014 contained, _x001A_Please make sure [RV1] has a bath/shower on Wednesdays and Sundays at the least._x001A_ On or about July 28, 2014, RV1 reported that he/she had not had a shower since July 9, 2014. RV1 also indicated that he/she had not received daily foot care. The facility failed to provide appropriate care and services. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV148661A,520161,AFH,9/14/2014,"On or about 9/17/14, APS received an allegation that RP1 failed to provide appropriate care to RV1. During the course of the investigation, APS substantiated that RV1 has two separate and serious conditions, for which RV1 should not eat foods high in fiber. RP1 served RV1 foods with high fiber content. RV1's medical diagnosis requires insulin to be administered at scheduled times. Facility did not complete a screening or care plan, nor did facility ask about dietary information from RV1's doctor at the time of screening. RP2 and facility staff did not: administer insulin at scheduled times, administer accurate insulin amounts per physician's orders, did not moniter insulin administration, or did not document insulin administration. Due to facility's failure in regard to proper adherence to RV1's medical orders and treatments, RV1 had dangerously high CBG levels. RV1 has a physician's order for facility to notify the physician whenever RV1's CBG levels are 450 or higher. RV1's CBG readings were over 450 on 16 occasions during August and September 2014. APS found no documentation of facility contacting physician on any of these occasions except for on September 14, 2014. RV2 did not receive prescribed pain medication from 9/22/14 through 9/29/14 and facility did not arrange for or provide appropriate transportation for RV2 when needed to get to a medical appointment. The facility failed to follow physician's orders. This failure is considered neglect and constitutes abuse.",3,1000,,,Neglect +MV148661D,520161,AFH,9/14/2014,"On or about 9/17/14, APS received an allegation that the facility failed to provide a safe and secure environment. During the course of the investigation, APS determined that an argument occurred between RV1 and facility staff RP1, in which a drinking glass hit the floor and shattered. RP1 did nothing to assist clean up of glass on the floor, putting residents at risk of injury. RV1 received a cut on his/her foot from the broken glass. Emergency personnel called to the scene cleaned broken glass from the floor of the kitchen/dining area. Facility's failure to provide a safe environment exposed residents to potential harm. Facility's failure is a violation of resident's rights, constitutes neglect, and is considered abuse.",2,,,,Neglect +ES104427,520190,AFH,5/19/2010,"RP1 told RV1 that RV1 could not go outside early to smoke (around 5:30 or 6:00 AM) and that if he/she did, RP1 would take control of RV1's tobacco. On May 19, 2010, RV1 went outside to smoke at about 5:45 AM. RP1 went outside and physically took RV1's tobacco, lighter and cigarette by grabbing RV1's right hand.",2,0,,,Physical Abuse +ES129363B,520190,AFH,2/24/2012,"On or about February 24, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). It was determined through interviews and observations that RV did not receive all of his/her prescription pain medication in 2/2012. The licensee failed to provide a safe medication administration system for RV. The failure is a violation of Oregon Administrative Rules.",0,0,,, +GP105403,520194,AFH,9/30/2010,"On or about Spetember 30, 2010, Licensee got into a physical altercation with Resident 1. Resident 1 suffered minor to moderate harm. Licensee failed to protect Resident 1 from physical abuse.",3,0,,,Physical Abuse +CO16052,520204,AFH,3/8/2016,,3,,,, +CO12059,520223,AFH,3/6/2012,"Licensee failed to provide a safe medication administration system, failed to ensure caregivers had completed caregiver preparatory workbooks, failed to do proper assessmrnts of residents, and failed to have a smoke detector in the caregivers bedroom.",2,700,,, +JG133015,520240,AFH,4/9/2013,"On or about April 10, 2013, it was alleged that Reported Perpetrator (RP) failed to assure Reported Victim's (RV)) resident rights. RV had a history of falls. It was explained to RP that RV is a two person assist with mobility. It was documented three times that Witness#7 (W7) was the only caregiver providing care. On or about April 7, 2013, RV fell. Emergency personel was contacted. RV was changed out of h/h clothes but did not cooperate in allowing new clothes to be put on. RV was transported to the hospital without any clothes on and only a blanket to cover h/h. Emergency nursing record dated 04/07/2013 notes that there was a ""foul smelling urine saturated diaper on arrival."" The record also notes that RV ""had no clothing."" The licensee failed to assure RV's resident rights. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +JG145763,520240,AFH,9/27/2012,"On or about October 15, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) from inappropriate verbal comments. Reported Victim #2 (RV2) observed Reported Perpetrator #2 (RP2) ""yelling"" at RV1 to pick up his/her mess. RP2 denied raising his/her voice toward any RV. The licensee failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV105879,520252,AFH,11/15/2010,"On or about November 15, 2010 it was reported that the Licensee failed to provide a safe environment. Interviews concuded that Resident #2 (RV2) was acting out in a threatening way toward Resident #1 (RV1), and waiving a pocket knife in front of RV1 in a threatening manner. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV117105,520252,AFH,3/18/2011,Witness #1 (W1) was employed by Reported Perpetrator #1 (RP1). W1 received training and a delegation to administer an injection to Resident #1 (RV1). W1 stopped working for RP1 and RV1 made an appointment to administer the injection with his/her physician until someone else could be delegated. RP1 and Reported Perpetrator #2 (RP2) made an effort to locate another nurse to complete the delegation for RP2. No one could be located and RP2 administered the injection to RV1. It was determined that no delegation should have ever taken place as the injection was intra-muscular and not appropriate according to the Oregon Administrative Rules.,2,0,,, +CO13093,520252,AFH,7/19/2013,"On July 19, 2013, the licensor made an unannounced visit to the licensee_x001A_s adult foster home (AFH). During the visit the licensor discovered that caregiver MR had not completed the orientation to the AFH, the caregiver preparatory workbook or the criminal records check as required and was left alone with residents on 7/18/2013. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. FOD sent 9/12/13- Payment received 10/7/13",3,250,,, +CO14051,520252,AFH,3/7/2014,Condition Withdrawn 5/2/14,4,0,,,Sexual abuse +WB145946,520252,AFH,1/29/2014,"On or about January 31, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) was heard calling RV a ""pain in the ass"" and has been observed being verbally aggressive toward RV. RP2 acknowledged that on one occasion he/she may have ""hollered a little louder."" It was reported to Witness #1 (W1) that this has made other residents uncomfortable. The licensee failed to assure RV's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES116264,520285,AFH,2/1/2011,"On or about February 2, 2011, Licensee made an inappropriate comment to Resident 1",2,0,,, +ES134145A,520285,AFH,8/16/2013,"On or about August 16, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #1 (RV1), Reported Victim #2 (RV2) and Reported Victim #3 (RV3). RP limits access to food and snacks for RV's during the evening and night by locking the refigerator. The licensee failed to provide appropriate service to RV's. The failure is a violation of Oregon Administrative Rule.",2,,,, +ES134145B,520285,AFH,8/16/2013,"On or about August 16, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #3 (RV3) from inappropriate verbal comments. RP was heard telling RV3 ""no, this is not your home."" RP has been heard yelling at RV3. RP called RV3 a ""fucking client."" The licensee failed to protect RV3 from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rule.",2,,,, +KF103970,520331,AFH,4/8/2010,"On or about April 8, 2010, approximately 28 pills were missing from Resident #1, 16 pills from Resident #2, and 13 pills from Resident #3. Reported Perpetrator #2 (RP2) acknowledged taking Resident #1's pills. The provider reported the incident to all parties and immediately suspended RP2.",3,0,Not Substantiated,Substantiated,Financial abuse +KF117755,520331,AFH,8/18/2011,"On or about August 18, 2011, it was reported that Resident #1 (RV1) was not receiving appropriate care. The investigation concluded that the Licensee had failed to conduct a proper screening prior to admitting RV1 to Licensee's adult foster home and failed to adequately staff in order to provide safe and appropriate care to RV1.",2,0,,, +BH121837,520355,AFH,11/27/2012,"It was reported that on or about November 27, 2012, Licensee failed to follow physician's orders for one of Resident #1's medications. Licensee failed to ensure Resident #1 received his/her ordered dose of medication. Licensee had difficulty getting Resident #1's medication filled at the pharmacy because Resident #1 had changed physician's and the medication needed to be authorized by Resident #1's new physician. As a result Reported perpetrator #1 and Reported perpetrator #2 cut Resident #1's medication dose in half and administered only half the dose ordered. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO11053,520357,AFH,4/5/2011,,2,250,,, +RB118030,520370,AFH,9/9/2011,"On September 9, 2011, Reported Victim (RV) sustained a fall in the Adult Foster home, as a result of the fall RV was transported to the hospital and received stitches for a laceration to the head. The care plan for RV states RV needs hands on assist, is unstable and cannot walk unassisted safely. On the date of the incident RV was seen walking unassisted. The licensee failed to follow the care plan. The failure is a violation of resident rights, is considered neglect of care, and constitute abuse. NOTE: email sent to AR to begin the aging process on 1/10/13",3,400,,, +MV132232,520496,AFH,1/23/2013,"It was reported that on or about January 23, 2013, Licensee failed to protect Resident #1 from inappropriate verbal comments. Licensee and staff do use the ""F"" word. Reported Perpetrator #2 (RP2) did post a note on a refrigerator that read ""Staff Fucking Fridge"". Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV134753A,520496,AFH,10/10/2013,"It was reported that on or about October 10, 2013, Licensee failed to provide appropriate care for Resident #1 (RV1). Facility staff left RV1 in dirty clothes did not clean RV1's dentures and did not provide bathing as appropriate. Licensee's failures are a violation of Oregon Administrative Rule (OARs), is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +MV147099,520496,AFH,5/16/2014,"RV1 had dried brown matter on h/h bed sheets. RV1's bedroom is missing parts of the wood flooring but does have subflooring down. RV2 was being given a narcotic PRN medication without the AFH having MD orders. RV2's narcotic pain medication was not being tracked on the MARs. On 5/16/14 W1 wasn't aware of the MARs for RV2's narcotic medication but signed RV2's narcotic medication on 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/16, 5/17, and 5/18.",2,,,,Neglect +GB148941,520498,AFH,10/13/2014,"It was reported that on or about October 13, 2014, Licensee failed to provide appropriate medical care to Resident #1 (RV1). On August 25, 2014, RV1 was discharged from the hospital with orders to have a chest x-ray and then follow up with his/her physician. Reported Perpetrator #2 (RP2) failed to ensure RV1 made it to his/her follow up appointments resulting in RV1's medication not being refilled and RV1 going without his/her medications. RP2's failures and Licensee's failures are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +GB149430A,520498,AFH,12/2/2014,"It was reported that on or about December 2, 2014, Licensee failed to provide appropriate care and services to Resident Victim #1 (RV1). RV1 woke up complaining of knee pain at 8:00AM on December 2, 2014, and told Reported Perpetrator #2 (RP2) he/she wanted to go to the hospital emergency room (ER). RV1 agreed to wait until after breakfast to go to the ER because he/she wanted to bathe and wanted clean clothes prior to going to the hospital. RP2 left the facility to run errands and left Reported Perpetrator #3 (RP3) in charge at the Adult Foster Home. RV1 continued to complain to RP3 that he/she was in pain and requested on multiple occasions to be bathed so he/she could go to the hospital. At 1:26 PM on December 2, 2014, an ambulance was called and RV1 was transported to the hospital without having been bathed and without having an opportunity to change into clean clothes as requested. Licensee's failure is a violation of AFH OARs, and abuse has been apportioned to RP2. Wrongdoing was substantiated.",3,0,Not Substantiated,Substantiated,Neglect +GB151871,520498,AFH,7/8/2015,"It was repoerted that on or about July 8, 2015, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee placed a physical restraint (bed rails) on RV1's bed. Licensee did not obtain physician's orders for the use of RV1's bed rails as requiored. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +RS118214A,520505,AFH,10/11/2011,"On or about October 11, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), and Reported Victim #4 (RV4). It was determined through interviews that Reported Perpetrator #2 (RP2) served raw or undercooked food to RV's. The licensee failed to provide a safe environment for RV1, RV2, RV3, and RV4. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RS118214B,520505,AFH,10/11/2011,"On or about October 11, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), and Reported Victim #4 (RV4). It was determined through interviews that Reported Perpetrator #2 (RP2) was not providing care to RV's. RP1 acknowledged that RP2 was not at the Adult Foster Home (AFH) to provide care, but to ""housesit"". The licensee failed to provide appropriate service to RV1, RV2, RV3, and RV4. The failure is a violation of Resident Rights and constitutes abuse.",3,0,,,Neglect +RS118214C,520505,AFH,10/11/2011,"On or about October 11, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to treat Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), and Reported Victim #4 (RV4) with respect and dignity. It was determined through interviews that Reported Perpetrator #2 (RP2) was rude to RV's and yelled at RV's. The licensee failed to assure RV1, RV2, RV3, and RV4's resident rights. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RS118214D,520505,AFH,10/11/2011,"On or about October 11, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to maintain an adequate medication administration system for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), and Reported Victim #4 (RV4). It was determined through interviews and observations that RV1 did not receive an ordered nausea medication, RV3 did not receive his/her medications on 10/11/11, and RV4 did not receive his/her nighttime medication. The medication administration record (MAR) for RV1, RV3, and RV4 supports this. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",0,0,,, +CO13096,520508,AFH,5/6/2013,"On May 6, 2013, the licensor conducted an annual renewal visit at the licensee_x001A_s adult foster home (AFH). During the inspection the licensor discovered that the only caregiver on duty (CC) did not have a cleared criminal records check as required. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. UPDATE: FOD delivered 9/14/13. Notified AR to begin aging process 11/12/13",3,250,,, +RB148251,520508,AFH,8/23/2014,"Resident #1 (RV) was prescribed a blood sugar medication. Another resident (R2) in the AFH had been prescribed the same medication in the past; however, the medication was discontinued for him/her and R2 no longer needed it. At the time the medication was discontinued, R2 had remaining doses of his/her blood sugar medication. R2's discontinued medication was not disposed of by the Licensee. During the course of the investigation, Licensee acknowledged that Licensee administered R2's discontinued medication to RV. Licensee failed to dispose of R2's discontinued medication, failed to dispense medication to RV that was solely in the original container with a pharmacy label that listed RV's name and failed to provide a safe medication administration system. Licensee's failures are violations of Oregon Administrative Rule.",2,,,, +CO15220,520540,AFH,10/26/2015,"Provider did not have a qualified caregiver in the home twice. Provider left the country for more than 10 days without informing local licensing authority of staffing plan and who would be primary caregiver while she was away. Also, when questioned by the local licensing authority, she stated that she had no caregivers working for her since January or February of 2015; but later admitted that she had a caregiver working for her part-time on weekends.",3,550,,, +NB150267A,520542,AFH,2/17/2015,"On or about February 17, 2015, APS received a complaint that the facility failed to protect RV1 and RV2 from the theft of narcotic pain medication. During the course of the investigation, APS substantiated the following: on 2/17/15, it was discovered that 48 tablets of narcotic medication for pain belonging to RV1 had been taken and replaced with 48 tablets of non-narcotic pain medication. It was also discovered that 12 tablets of narcotic pain medication belonging to RV2 were missing and that the remaining 20 tablets had been taken and replaced with non-narcotic medication for pain. It is possible that all tablets (60 of each medication) had been taken and replaced with non-narcotic pain medication. Various people had access to the narcotic medication and it is unclear who took the medications. Theft of medications is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +ES121290A,520561,AFH,10/7/2012,"It was reported that on or about October 7, 2012, Licensee failed to protect Resident #1 from inappropriate verbal comments. Licensee admitted to becoming frustrated with Resident #1 and told Resident #1 to shut up. Licensee's failures are a violation of Oregon Administrative Rules and constitute verbal abuse",2,0,,, +CO14028,520565,AFH,1/17/2014,"On January 17, 2014, the local licensing authority received information that (LF) had been using another individual_x001A_s name (FE) and identification when she/he filled out the criminal records check and had been working in the licensee_x001A_s adult foster home (AFH) unqualified. The licensors conducted an unannounced visit to the AFH. Upon arrival LF and another caregiver were working in the AFH. LF confirmed that she/he had not completed a criminal records check for the AFH since she had been employed by the licensee. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. + + + +During the visit on January 17, 2014, LF confirmed that she/he had used FE_x001A_s name and identification when she/he filled out the criminal records check form. The licensors verified that LF had never filled out a criminal records check using her/his own name and identification. During a conversation with the licensee on January 17, 2014, the licensee acknowledged that the criminal records check was being falsified. The licensee stated that she knew it was wrong but she was just trying to help out LF. UPDATE: 4/11/14 FOD Completed this date. Notified MFU. UPDATE: Non-Renewal issued, Home closed 7/23/2014",3,700,,, +CO14113,520565,AFH,6/10/2014,Non-Renewal signed and sent on 7/18/14,4,,,, +CO14114,520565,AFH,6/10/2014,"On June 3, 2014, the Department received information that the licensee was arrested for multiple counts of identity theft, false claim of healthcare payment and theft in the first degree. The licensee demonstrated she does not possess the good judgment, truthfulness, and good personal character determined necessary by the Department to operate an adult foster home (AFH). The licensee failed to maintain the required qualifications. These failures exhibit the potential for minor to serious harm. Licensee_x001A_s actions are a violation of Resident Rights. UPDATE: Non-renewal issued 7/23/2014. Licensee did not request a contested case hearing. AFH Closed.",3,,,, +BO146764,520565,AFH,4/1/2014,"Resident #1 admitted to licensee's adult foster home #1 (AFH1) on February 28, 2014. Resident #1 (RV1) exhibited behavioral issues and licensee moved him/her to licensee's adult foster home #2 (AFH2). Documentary observations indicate that no new screening and assessment was conducted upon RV1's admission to AFH2 on or about March 5, 2014. On or about April 1, 2014, Resident #1 became very upset when licensee would not give him/her additional medication. Licensee asked Resident #2 (RV2) to assist him/her because RV1 was ""out of control"". RV2 stood between licensee and RV1. Licensee failed to exercise reasonable precautions to protect all residents and failed to conduct a new screening and assessment upon RV1's admission to AFH2. Licensee's failures are violations Oregon Administrative Rule.",2,,,, +MM105882A,520596,AFH,11/18/2010,"On or about November 2010, Licensee failed to protect Resident 1 from inappropriate comments. Caregiver 1 made derogatory comments to Resident 1's physician.",2,0,,, +MM105882B,520596,AFH,11/18/2010,"On or about November 2010, Licensee failed to provide a safe environment preventing egress from the adult foster home. This action places residents at risk for moderate to severe harm.",2,0,,, +MM105882C,520596,AFH,11/18/2010,"On or about November 2010, Licensee failed to ensure Resident 1 received pain medication per physician orders. Caregiver 1 acknowledged to Resident 1's physician he/she did not give Resident 1 his/her PRN pain medication. Resident 1 suffered pain as a result of this failure.",0,0,,, +MM116616,520596,AFH,12/1/2010,"On or about November 2010 through March 2011, Licensee failed to ensure Caregiver 1 administered medications to Resident 1 per physician orders. Resident 1 was hospitalized and suffered moderate harm.",3,450,Not Substantiated,Substantiated,Neglect +MM133458A,520596,AFH,6/6/2013,"On or about June 6, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #1 (RV1) and Reported Victim #2 (RV2). RV's are not allowed to use the dishwasher. RV2 washes dishes by hand and verbally expressed that he/she does not want to. RV1's Medication Administration Record (MAR) was not initialed from 5/24/13 through 6/10/13. The licensee failed to provide appropriate care. The failure is a violation of Oregon Administrative Rule.",2,,,, +MM133458B,520596,AFH,6/6/2013,"On or about June 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from inappropriate verbal comments. When Reported Perpetrator #2 (RP2) is upset RP2 ""throws stuff around"" and ""slams cabinet doors"". RP2 verbally told RV1 that he/she did not want RV1 at the Adult Foster Home (AFH). RV2 asked that RP2 not be informed that RV2 made any statements for fear that RP2 would ""get mad"". The licensee failed to protect RV1 and RV2 from mental or emotional abuse. The failure is a violation of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +MM132046A,520596,AFH,12/20/2012,Individually Apportioned,2,,Not Substantiated,Substantiated, +MM132046B,520596,AFH,12/20/2012,"On or about December 20, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to administer an ordered medicaiton to Reported Victim #1 (RV1) and Reported Victim #2 (RV2). Witness #14 (W14) stated that RV2's therapeutic range for INR on 11/28/2012 indicates that RV2 missed at least one does medication. While on duty Witness #5 (W5) discovered that RV2 was not administered his/her medication over the thanksgiving weekend. The licensee failed to administer an ordered medication. The failure is a violation of Oregon Administrative Rules.",2,,,, +DA132115,520618,AFH,12/31/2012,Resident #1 had an existing private pay contract with the licensee when Resident #1 experienced a change in condition while living at licensee's adult foster home (AFH). Licensee hired two additional caregivers and began billing Resident #1 for additional care and services without amending the private pay contract and obtaining an authorized signature. Licensee failed to provide thirty days written notice prior to a imposing a rate change. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV146674,520618,AFH,3/19/2014,"Resident #1 (RV1) was diagnosed with a cognitive impairment on or about February 21, 2013. Licensee conducted a pre-admission screening and assessment of RV1 on or about February 26, 2013. Documentation from Licensee_x001A_s screening and assessment of RV1 includes Licensee_x001A_s knowledge of RV1_x001A_s diagnosis of cognitive impairment. + + + +RV1 admitted to Licensee_x001A_s adult foster home (AFH) on or about March 6, 2013. RV1 whose diagnosis of cognitive impairment was known to the Licensee signed a private pay contract on March 6, 2013. Witness #4 (W4) reported that AFH staff also knew that RV1 had a cognitive impairment when he/she moved into the AFH. + + + +The written agreement that RV1 entered into with the Licensee on March 6, 2013 was based on a standard rate of $3,500.00 per month with no add-on services. In March 2013 RV1 was billed for the dates of March 4, 2013 through March 31, 2013 which included two days prior to RV1_x001A_s arrival to Licensee_x001A_s AFH. + + + +On or about March 10, 2013, four days after RV1 signed the original contract, Licensee increased the rate. The letter of rate increase mentioned a per day rate of $175.00 instead of the monthly rate agreed to on March 6, 2013. No updated contract was prepared by the Licensee. No signature of agreement was obtained from RV1 or RV1_x001A_s designee. + + + +The billing statement for April 2013 included add-on services valued at $450.00. RV1 was also invoiced $151.98 for miscellaneous items. No documentation of the extra charges was provided to RV1 or RV1_x001A_s designee(s). + + + +The billing statement for May 2013 included add-ons totaling $1,750.00, $475.00 for incontinence of bladder, $575.00 for incontinence of bowel, and $700.00 for extra night care staff due to wandering. Additionally, the invoice billed RV1 for miscellaneous items totaling $168.00. A new contract was not signed by RV1_x001A_s power of attorney until May 11, 2013. The contract included a statement that when extra services were no longer needed, the amount of add-ons would be reduced. + + + +Witness #1 (W1) reported that in the following months there were add-ons to the standard rate which exceeded the agreed upon monthly total of $5,250.00. When RV1_x001A_s long-term care insurance began paying for RV1_x001A_s care, the contract was written for $5,250.00 per month but the Licensee began charging $5,425.00. The difference was invoiced to RV1. W1 further reported that the Licensee increased the daily rate from $175.00 to $185.00. Witness #2 (W2) also reported that the Licensee failed to provide an itemized breakdown of any of the expenses when requested by RV1_x001A_s designee(s). + + + +Despite the contract that was signed in May 2013, Licensee remained billing for add-on services that were later identified as inconsistent with RV1_x001A_s needs at the time he/she left the AFH. Witness #5 (W5) reported that RV1 was incontinent of bladder only half of the time when RV1 was placed on a routine bathroom schedule and he/she dad not experienced a bowel movement in which he/she did not use the bathroom. W5 stated that he/she had not observed any exit seeking behaviors and slept through the night. + + + +The last invoice that was issued prior to RV1 moving from Licensee_x001A_s AFH was for $5,700.00. No written notice was given to RV1 or RV1_x001A_s designee 30 days prior to the rate increase. + + + +On or about March 19, 2014, RV1 moved out of Licensee_x001A_s AFH due to multiple occasions when Licensee failed to give written notification to RV1/RV1_x001A_s designee 30 days in advance of rate changes, failed to provide itemized breakdown of miscellaneous supplies and failed to amend the private pay contract and obtain an authorized signature of agreement whenever any element of the contract changed. + + + +W1 also reported that RV1_x001A_s incontinent supplies were missing when RV1 moved out of the AFH and Witness #6 (W6) confirmed that no incontinent supplies were sent with RV1 when he/she arrived at his/her new facility. + + + +Licensee billed RV1/RV1_x001A_s representative for 21 days as Licensee was not given a 30-day move-out notice. The invoice included an amount for supplies which were not used during that time period as RV1 was no longer living in the AFH. Additionally, Licensee initially kept two of RV1_x001A_s Thomas Kincaid pictures valued at over $1,700.00. Licensee stated she intended to retain the pictures until she received payment for the outstanding balance but returned them after Witness #3 (W3) advised Licensee that she could not keep them. + + + +Licensee failed to provide proper notice of rate increases, failed to ensure that contracts were amended and signed by RV1_x001A_s designee and charged RV1 beyond RV1_x001A_s last day in the home despite RV1 leaving the AFH due to abuse that was + + + +substantiated by the Department. Licensee_x001A_s failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,450,Substantiated,Substantiated,Financial abuse +CO15117,520618,AFH,6/19/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +CO15125,520618,AFH,6/22/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +ES147096C,520641,AFH,5/15/2014,"On or about May 16, 2014, it was alleged that Reported Perpetrator (RP) failed to intervene when Reported Victim #2's (RV2) condition changed. On April 19, 2014, Reported Victim #1 (RV1) heard a loud smack. RV1 discovered RV2 face down on the kitchen floor. RV1 yelled for help. A caregiver came to assist RV2 in getting up but could not do it by him/herself. RV1 assisted the caregiver in getting RV2 up. RV2 complained of pain and sustained a bruise and small cut on the wrist as a result of the fall. The licensee failed to provide a safe environment for RV2. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO16153,520679,AFH,5/17/2016,"On May 17, 2016, the Department received preliminary information for Adult Protective Services (_x001A_APS_x001A_) alleging sexual abuse by caregiver Steven Nettles (_x001A_S.N._x001A_). Resident #1 reported that while receiving care in the bathroom of the AFH S.N. touches him/her on the buttocks/genital area. Resident #1 has reported that S.N. has put his finger inside Resident #1_x001A_s rectum, touches Resident #1_x001A_s genitals, and kisses him/her on the top of his/her head.",4,,Substantiated,Substantiated,Sexual abuse +JG117108,520686,AFH,4/7/2011,"On or about March 27, 2011, Licensee ran out of Resident #1's narcotic pain medication. Resident #1 did not receive this medication for approximately 10 days until the refill was delivered to the adult foster home on or about April 5, 2011. Staff began administration of the narcotic pain medication on April 6, 2011. On April 7, 2011, Caregiver #1 administered the narcotic pain medication an hour before it was ordered to be administered. As a result, Resident #1 stopped breathing, 9-1-1 was called, an anti-overdose medication was administered and Resident #1 was transported to the hospital. Licensee_x001A_s failures are a violation of resident rights and constitute abuse.",4,750,,,Neglect +NB148383,520698,AFH,9/4/2014,The licensee failed to update the care plan for R2 as required. RP2 failed to provide a safe environment for R1 and R2. These failures resulted in moderate harm to R1.,3,400,Substantiated,Substantiated,Neglect +RS164697,520738,AFH,2/15/2016,"It was reported that on or about February 15, 2016, Licensee failed to maintain an adequate medication administration system resulting in Resident #1 being administered another resident's medications. Wrongdoing on the part of Reported Perpetrator #1 was substantiated. Reported Perpetrators #2's failure is considered neglect and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +GP120206,520794,AFH,6/6/2012,"On or about June 6, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3). It was determined through interviews and observations that Witness #3 (W3) was providing care, alone to all RV's without having a cleared criminal records check. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rule.",3,0,,, +MS118627,520800,AFH,12/5/2011,"On or about December 6, 2011, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to provide appropriate care to Reported Victim (RV). Through interviews and observations it was determined that the licensee was to provide appropriate care and services for RV. The licensee failed to provide a needed service to RV resulting in RV's unreasonable discomfort.",2,0,,, +BO132416,520819,AFH,2/8/2013,"On or about February 8, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). It was documented that RV fell on 8/29/12 in the restroom while unattended. RV complained of pain on the back of h/her head and sustained injury to h/her tailbone as a result of the fall. On 11/25/12 it was documented that RV was found on the floor in the bathroom unattended. RV complained that h/h left hand and leg was in pain. RV sustained a bruising on h/h ankle and upper right arm as a result of the fall. On 1/9/13 it was documented by the facility that RV fell while in the restroom unattended. RV was discovered on the floor on h/h back and head at a 90 degree angle. RV's eyes were rolled back into h/h head and RV was non-responsive. Blood was seen running from the tub to the floor. Emergency personel was contacted and RV was transported to the hospital for treatment. RV sustained a cut to h/h head that required stitches and bruising to RV's left knee. It was determined that the licensee failed to properly careplan for RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +BO133959,520819,AFH,6/17/2013,"On or about June 17, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from rought treatment. RP approached RV to discuss issues that RP was having surrounding RV's care. RP and RV had a physical altercation. RP states that it was RV that struck RP first and RP placed RV in a head lock to deescalate the situation. RV states that RP struck him/her in the face first and RV was trying to defend him/herself. RV's care plan dated 3/8/2013 indicates that RV has limited mobility and instructs staff to stand by for assistance as needed. As a result of the altercation RV sustained an injury approximately 1 inch across directly below his/her right eye. The licensee failed to protect RV from rough treatment. The failure is a violation of resident rights and costitutes physical abuse.",2,,,,Physical Abuse +CO14111,520826,AFH,6/17/2014,Unqualified caregiver left alone with residents. FOP SENT OUT TODAY,3,250,,, +AL147953,520832,AFH,11/19/2012,"It was reported that on or about November 19, Licensee failed to provide Resident #1 (RV1) with appropriate care and services. Licensee's failures are considered a violation of Oregon Administrative Rules (OARs). Reported Perpetrator #2's (RP2) failures are considered physical abuse. Wrongdoing on the part of the Licensee and RP2 was substantiated and abuse has been apportioned to the RP2 in this case.",4,,Not Substantiated,Substantiated,Physical Abuse +CO14224,520832,AFH,10/28/2014,"_x001A_ On or about August 13, 2014, the licensor received a complaint that a resident who requires insulin shots was admitted into the licensee_x001A_s adult foster home (AFH) on August 11, 2014, and none of the caregivers had been delegated by a Registered Nurse as required to give subcutaneous injections. The licensor conducted a visit to the AFH on August 13, 2014. The licensee stated that Resident #1_x001A_s (R1) spouse was giving the injections. On August 14, 2014, the licensee obtained physician orders for R1 allowing R1 to self-administer the insulin. In an email dated August 10, 2014, to the caregivers of the AFH the licensee stated _x001A_Because we will not have a nursing delegation for checking his/her blood sugars or insulin, he/she will need some assistance to get things done. You can get everything set up for him/her to do and hold it if necessary as he/she presses the plunger to pierce his/her skin._x001A_ The licensee failed to obtain delegations as required. + + + +_x001A_ The licensor conducted a follow up visit on August 21, 2014. The licensor discovered that the licensee was not living in the AFH and there was not an approved resident manager in place. The licensee failed to maintain qualifications as required.",3,400,,, +CO15008,520832,AFH,1/12/2015,"Local office requested mandatory civil penalty based on unqualified caregiver working without a background check. Also, no primary caregiver in this home since 2013, despite repeat conversations and violations.",2,500,,, +KF134210,520837,AFH,8/23/2013,"Resident #1 (RV) had a prescription for pain medication. Between the dates of August 30, 2012 through July 31, 2013, the pharmacy dispensed a total of 240 tablets of RV's pain medication. A review of RV's Medication Administration Records between September 1, 2012 and July 31, 2013 indicate the RV was administered 51 tablets. RP2 continued to refill the pain medication without reconciling the total number of doses dispensed against the number of tablets remaining. The total number of tablets unaccounted for during this period of time was 189. + + + +RV's pain medication is kept in a medication cabinet which is located in RP2's bedroom. Both RP2 and RP3 have access and keys to the medication cabinet. RP2 leaves the key to the medication cabinet in the lock. The investigation failed to conclusively identify who diverted the medication. Facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Financial abuse +KF153117,520837,AFH,10/12/2015,"RV requires assistance in every care need, and is unable to provide for his/her own activities of daily living. RV tires easily, can walk approximately ten feet with assistance, and needs assistance transferring. RV needs assistance with toileting, uses a bedside commode, and has agreed to use an incontinence undergarment. When RV calls for help RP1 often does not respond. RP yells at RV for needing assistance, and doubles up his/her fist while yelling. RP1 placed RV's bedside commode in the closet so RV could not easily get to it. On one occasion RV got up to use the commode and got trapped between the commode and the closet door. RV yelled for help but no one responded. After about half an hour RV was able to get back in bed. RP told RV s/he would not take RV to the bathroom ""every five minutes,"" and said instead, ""go in your diaper, that is what it is for."" RV's baby monitor was disconnected and RV could not get help when needed. RV is fearful of RP.",3,800,Substantiated,Substantiated,Verbal/Mental abuse +CO11128,520839,AFH,8/17/2011,"An annual licensing renewal visit was conducted at the licensee_x001A_s AFH on August 17, 2011. The Licensor discovered that the criminal records check of an occupant (SM) of the home, who also provides care, had expired on July 16, 2011. Licensee_x001A_s failure to ensure a safe environment is a violation of Oregon Administrative Rules (OARs).",3,250,,, +CO15200,520839,AFH,9/24/2015,Licensee did not have a functioning intercom system as she had turned it off at her end. Resident got up in the middle of the night and left the facility. Resident fell due to steep driveway and sustained multiple injuries and head trauma. Another resident contacted emergency services and the resident who fell died at the hospital as a result of injuries.,4,0,,, +KF152717,520839,AFH,9/5/2015,"On or about September 8, 2015, Adult Protective Services (""APS"") received a complaint that RP1 failed to provide a safe environment, resulting in serious injury. During the course of the investigation, APS substantiated the following: RV lacked the ability to meet RV's basic safety needs due to cognitive impairment. On September 6, 2015, at approximately 4:30 a.m., RV left the facility unaccompanied and experienced a fall in the driveway. RP's bedroom was not located in close enough proximity to hear RV leave or W4's attempts to alert RP. RP's monitoring system was not operating. W4 called 911 and RV was transported to the hospital. RV passed away on September 9, 2015, immediate cause of death listed as complications of blunt trauma due to the fall. RP's failure to maintain a safe and secure environment is a violation of resident rights, is considered neglect, and constitutes abuse.",4,0,Substantiated,Substantiated,Neglect +PT147667B,520851,AFH,6/10/2014,"On or around June 10, 2014, APS received an allegation that RP withheld medications, gave RV another resident's medications, and didn't provide proper care to RV. During the course of the investigation, APS determined that RP denied RV's medications were ready to be picked up, even though RV contacted the pharmacy and confirmed that they were. RP then changed RP's statements when a witness arrived at the facility with the medications. RP then stated that the pharmacy wouldn't release the medications. The medications were ready to be picked up on 5/9/14 but were not picked up until 5/11/14. Facility's failure to provide service constitutes neglect and is considered abuse.",3,200,,,Neglect +PT147667A,520851,AFH,6/10/2014,"RV moved out of the facility and had multiple items missing after the move. Among the list of missing items, were several packages that were delivered to RP's address after RV moved out. The online receipts show that the items delivered to RP's address were two packages on 5/16/14, one package on 5/17/14, and one package on 5/24/14. Although RP states that the items were never delivered to RP's address, and denies having any of RV's property, the packages could not have been intercepted prior to delivery at RP's address. RP's failure to protect RV from financial exploitation is considered neglect and constitutes abuse.",3,400,,,Neglect +PT150615,520851,AFH,1/20/2015,"On or about 1/30/15, APS received a complaint that the facility failed to assess and intervene. During the course of the investigation, APS substantiated that the resident (RV) died on 1/20/15 and that, although RV was full code and had a POLST requiring attempt at CPR, signed by the RP, RP did not attempt CPR. Although RP reported to APS that he/she contacted police, RP did not. RP instead contacted the funeral home to come pick up the deceased's body and the funeral home contacted the police. It was reported that RP did not give RV his/her seizure medications for approximately 2.5 weeks. RP stated that Witness 2 (W2) would always pick up RV's medications and that the last time the medications were picked up, it was by W2. The last time medications were filled (11/27/14) and picked up (12/4/14) W2 was out of the state. RP was able to pick up RV's medications. RV's seizure medication was not refilled at any local pharmacy in January 2015. RP stated that RV had been in another facility for one month (December 2014) and therefore RP had an extra month's worth of medications that RP gave RV during January 2015. RV was actually at another facility for 2.5 weeks in December 2013. RP also stated that W2 was always at the AFH, 24 hours a day, 7 days a week. W2 works out of state for several months a year and had left the state November 12, 2014, returned for Christmas, and left again December 28, 2014. The medications that RV claimed to have from the stay at another facility would have been expired by January 2015. RP claimed that RP had destroyed the medications but had no documentation of disposal. RP's actions and failure to intervene when resident's condition changed are both a violation of Oregon Administrative Rules, but are also a violation of resident rules, constitute neglect, and are considered abuse.",2,,,,Neglect +CO15137,520851,AFH,7/10/2015,"At the time of monitoring inspection, neither the Licensee nor her caregiver had approved background checks (both had expired). The only ""caregiver"" in the home when the LLA arrived was Licensee's son, who also did not have an approved background check since 2012. LLA issued violation and submitted for mandatory civil penalty.",3,250,,, +CO15164,520851,AFH,8/18/2015,Provider had a bedroom divided into two bedrooms and moved her son in the home. Son's bedroom did not have a smoke alarm. Mandatory civil penalty.,3,350,,, +PT152676,520851,AFH,7/16/2015,"On or about July 28, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to protect RV1 from misappropriation of resources. During the course of the investigation, APS substantiated the following: RP2 took residents on an outing and used RV1's debit card to purchase lunch for everyone. RP2 later had RV1 sign a note that RP2 paid RV1 back. There were multiple purchases made using RV1's debit card which either do not match facility notes of outings taken, RV1 denies making, or for which a question on the signature's validity exists. Everyone in the home has access to RV1's bedroom. RP2's use of RV1's bank card to purchase food for others besides RV1 is a violation of resident rights, is considered financial exploitation, and constitutes abuse. RP1's failure to protect RV1 from misappropriation of resources is also a violation of resident rights, is considered financial exploitation, and constitutes abuse.",2,250,Substantiated,Substantiated,Financial abuse +PT153436A,520851,AFH,9/23/2015,"On or about September 24, 2015, APS received a complaint that the facility failed to provide an adequate medication system. During the course of the investigation, APS determined that RV1 moved to a new facility and that RP sent RV3's medication, along with all of RV1's medications, to the new facility. RV1's medication bottles had more medication in them than they should have based upon quantity received and date filled. RP stated that RP adds old medications to the new bottles when the medications are refilled. RP did not follow Oregon Administrative Rules when changing one of the medication bottle's labels. While RP was in Salem on 10/27-28/15, multiple medications were charted as administered and signed with RP's initials. On 10/29/15 the MARs were written over with W9's initials. There is discrepancy as to who charted the MAR with RP's initials. RP's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.",3,1200,Substantiated,Substantiated, +PT153436B,520851,AFH,9/23/2015,"On or about September 24, 2015, APS received a complaint that the facility failed to provide appropriate care. During the course of the investigation, APS substantiated the following: RV2's care plan states that RV2 should have grooming task done daily and that a two-person assist hoyer lift is to be used at all times to transfer RV2. On multiple occasions, RV2's grooming task was not done. RP did not know how to use the hoyer, it was not seen in RV2's room until 10/29/15. RP does not always have two qualified caregivers on staff. RV2 often smells of urine and flies have been found in RV2's room and in the facility. RV2's care plan also states that he/she is to be observed while eating for choking hazard. W10 was in RV2's room while RV2 was eating. No other caregiver was in the room. RP's failure to provide appropriate care is a violation of resident's rights, is considered neglect, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +CO15249,520851,AFH,12/7/2015,Suspension request from local office due to life safety issues: inability to evacuate resident with staffing; multiple instances of abuse; multiple instances of falsification of medication administration records and medication errors even with conditions and training; unqualified staffing who do not speak English; etc. Discussed request with DOJ. Denied local office suspension request b/c of already ongoing action which addresses these issues. See AFHNR15-009.,4,0,,, +CO15251,520851,AFH,12/8/2015,Licensee falsified MARs. Repeat issue so aggravated civil penalty.,3,500,,, +AL118161,520852,AFH,2/25/2011,"On or about March 11, 2011 it was reported that the Licensee failed to assure timely medical treatment for Resident #1 (RV1). On February 25, 2011, at about 4:30 PM RV1 began having stomach pain, RV1 requested that the Licensee to contact 911 but RV1's request was denied. Licensee did not contact 911 until approximately 8:00 AM February 26, 2011. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +CO13095,520855,AFH,5/3/2013,Licensee had an underage caregiver working in his/her Adult Foster Home (AFH) who had not passed a criminal background check. UPDATE: FOD is complete 6/8/14 and an e-mail sent AR requesting the aging process begin.,3,200,,Substantiated, +CO12038,520868,AFH,4/24/2012,Licensee provides care to a relativeas a relative adult foster home. Licensee is unable to provide adequate care for the resident and is responsible for neglect and abuse.,3,0,,,Neglect +CO15209,520918,AFH,10/1/2015,Voluntarily surrendered - Non-renewal not needed,4,,,, +CO15148,520919,AFH,7/21/2015,#AFHSUS15-008 issued and delivered by hand on 07/24/15. Sent to DOJ for hearing. Ernie surrendered his Picadilly license as of e-mail sent to Deborah Salgado on 08/11/15.,3,,,, +CO15151,520919,AFH,7/24/2015,"This number was opened for NR/RV of license for Picadilly home. Per Deborah Salgado on 08/11/15, Safotu has vacated this home. Property owned by another individual.",4,,,, +MS152165A,520919,AFH,7/13/2015,"On or about July 22, 2015, the Department received a complaint that alleged the facility had failed to obtain timely medical care for Resident #1 (RV). The adult protective services investigation concluded that Licensee (RP1) and his staff (RP2) failed to notify RV_x001A_s medical practitioner when RV experienced a decline in his/her health from July 3, 2015 through July 12, 2015; failed to call for emergency services when RV experienced a significant change in his/her condition the morning RV died; and failed to complete a facility incident report regarding the circumstances that day. RP2_x001A_s conduct is a violation of resident rights, is considered neglect and constitutes abuse. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +MS152165B,520919,AFH,7/13/2015,"On or about July 22, 2015, the Department received a complaint which alleged the facility had failed to obtain and dispense an ordered medication for RV. RV_x001A_s medical professional prescribed an anti-allergy medication on February 16, 2015. The order was transmitted directly to RV_x001A_s pharmacy. When pharmacy staff notified Licensee (RP1) that RV would have to cover the cost of the medication, RP1 told pharmacy staff to not fill the order due to RV_x001A_s financial considerations. RV_x001A_s subsequent monthly Medication Administration Records (MAR) prepared by the pharmacy listed the anti-allergy medication. The pharmacy would not remove the prescribed medication from RV_x001A_s MAR without a discontinuation order from RV_x001A_s medical provider. During the course of the investigation, Witness #1 (W1) reported that RP1 did not contact RV_x001A_s medical provider to obtain an alternative medication. RV_x001A_s progress notes indicated that RV experienced itchy skin and had scratched at rashes on his/her feet. Licensee failed to provide a safe medication administration system. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MS152160,520919,AFH,7/21/2015,"On or about July 21, 2015, the Department received a complaint which alleged the facility had failed to provide a safe medication administration system. The Adult Protective Services Specialist determined that on July 9, 2015, the facility failed to have four of Resident #1_x001A_s (RV) prescribed medications available in the facility. RV was prescribed a bronchodilator (M1) in June 2014. A 30-day supply of M1 was last filled on March 16, 2015. A review of RV_x001A_s Medication Administration Records (MARs) for May 2015, June 2015 and July 1 through July 9, 2015 indicated that RV had been administered his/her bronchodilator medication (M1) daily during this time period. However, the number of administrations documented during this time span was inconsistent with the number of doses available. RV_x001A_s MARs also revealed that RV last received his/her thyroid medication (M2) on June 20, 2015. RV_x001A_s ordered Histamine blocker (M3) was last administered as directed on July 9, 2015. RV_x001A_s M3 was last filled on June 22, 2015. If M3 had been given as directed, there should have been sufficient stock to continue administration of M3. RV_x001A_s ordered antidepressant medication (M4) was last given on July 8, 2015. Licensee failed to have all currently prescribed medications on hand in Licensee_x001A_s adult foster home (AFH), failed to carry out all written medication orders and failed to maintain accurate medication administration records. Licensee_x001A_s failure to maintain a safe medication administration system is a violation of resident rights, is considered neglect and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +NB132788,520942,AFH,3/28/2013,"It was reported that on or about March 28, 2013, Licensee failed to provide Resident #1 with adequate care. When admitted to the hospital Resident #1 was found to have dirty ears, food in his/her mouth and smelled of urine. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +NB148247,520942,AFH,8/16/2014,"On or about August 25, 2014, a complaint was received that alleged the Licensee had failed to provide appropriate care and services to Resident #1 (RV). The investigation concluded that RV remained in a stool soiled brief for a few hours without being cleaned or changed. During the course of the investigation, it was also observed that the RV had a dark, dirty substance under his/her nails. Licensee failed to provide appropriate assistance with hygience. Licensee's failure is a violation of Oregon Administrative Rules.",2,,,, +BA106019A,520977,AFH,12/1/2010,"Reported Perpetrator #1's (RP1) medication administration called for placing medications in applesauce in cups. On December 1, 2010, RP2 gave Resident #1 (RV1) medications belonging to another resident. Once RP2 realized his/her error, he/she called emergency personell and RV1 was transported to the hospital for observation. RV1 returned to the facility after a few hours and did not have a negative reaction to the improper medicatons.",2,0,,, +BA106019B,520977,AFH,12/1/2010,Resident #1 (RV1) had cracked dentures and cracked ribs at the time of admission to the home. RV1 did not eat well for a period of time and lost weight. RV1 had a prescription for pain medication to be administered every 4 to 6 hours as needed. The medication was not administered frequently enough to control his/her pain. Once RV1's pain medication prescription was changed to a scheduled prescription he/she began eating better.,2,0,,, +BA106019C,520977,AFH,12/1/2010,"On December 1, 2010 Resident #1 (RV1) was taken to the hospital. At the time of transfer, RV1 had some food on his/her face and some matter in his/her eye and ear.",2,0,,, +BA106019E,520977,AFH,12/1/2010,Resident #1 (RV1) was to receive 4 medications for constipation in addition to prunes and other foods. Reported Perpetrator #1 (RP1) did not properly administer the medications resulting in constipation. RV1 liked milk but RP1 limited his/her consumption and told RV1 he/she could only have milk when she had a bowel movement.,2,0,,, +BA117246A,520977,AFH,5/2/2011,Adult foster home staff used chairs and their bodies to block Residents #1 and #2 from going into parts of the home. This was both for the safety of the residents and the convenience of the staff.,2,0,,, +BA117246C,520977,AFH,5/2/2011,"Resident #2 (RV2) is known to scream or cry, frequently disrupting other residents. Staff are often unable to calm him/her down. RV2 likes to attend church and staff will threaten to not let him/her go if he/she cries or screams. Reported Perpetrator #6 yelled at RV2 because RV2 accidently urinated on the couch, humiliating RV2.",2,0,,,Verbal/Mental abuse +BA117264,520977,AFH,4/28/2011,"On or about April 28, 2010 RP hooked his/her arms under RV's armpits and pulled RV into his/her room. On or about May 4, 2010 RP2 pulled RV by the back of his/her pants into his/her room. This action put RV at risk of physical harm.",1,0,,, +BA146304,520977,AFH,1/6/2014,"RV has a history of masturbating in his/her room when staff may be coming in to provide care. RP2 has made comments about RV touching h/hself in front of others. This has been regarded by others as disrespectful to RV, creating a loss of dignity. RP failed to assure residents rights, and failed to provide a safe and secure environment, resulting in loss of dignity.",2,,,, +BA146308,520977,AFH,12/20/2013,"Resident #1 (RV1) had written orders for two types of medications, one was long-acting (M1) and the other one was short-acting (M2). On or about December 20, 2013, RV1 was given M2 instead of M1. R1 later reported not feeling well and that his/her blood sugar was low and wouldn't raise despite interventions. RV1 experienced shaking, paleness, feeling clammy and difficulty in breathing due to the wrong medication being dispensed. Licensee failed to provide a safe medication administration system which resulted in harm to RV1. Licensee's failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +BA145928B,520977,AFH,1/15/2014,"Resident #1 (RV) and Individual #1 (RV2) reside at Licensee_x001A_s adult foster home (AFH). RV and RV2 both had physician's orders for the same type of blood thinning medication. On or about January 11, 2014, Witness #1 (W1) realized that RV2 did not have sufficient medication at the AFH to receive a full dose of his/her blood thinner. W1 contacted Reported Perpetrator #2 (RP2) for assistance. RP2 advised W1 to take one of RV_x001A_s 5mg blood thinner pills and give the medication to RV2. During the investigation, Licensee acknowledged that RP2 had done this. + + + +Licensee failed to protect RV from loss of medication intended for use by RV. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. The culpability for the loss of RV_x001A_s resources was apportioned to both Licensee and RP2.",2,,Substantiated,Substantiated,Financial abuse +BA146943,520977,AFH,3/4/2014,"Resident #1 reported that his/her toe was run over by a wheelchair. Licensee (RP) reported that this event occurred in December or January and that the toenail turned black. Resident #1's progress notes from February 25, 2014 through March 18, 2014 were reviewed. An entry dated February 27, 2014 documented that Resident #1 had stated his/her ""foot hurts like hell"" when he/she walks. A second entry that same day records Resident #1 reported that his left big toe hurt and that he/she was given two over-the-counter pain meds. Entries on February 28, 2014 and March 1, 2014 documented that Resident #1 complained of pain and wanted medication for the pain. Resident #1 was not taken to a medical professional until March 7, 2014. Licensee failed to report Resident #1's change in condition to his/her physician which resulted in prolonged pain to Resident #1. Licensee's failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +BA148133,520977,AFH,7/10/2014,"On or about July 10, 2014, it was alleged that Reported Perpetrator (RP) failed to properly use a restraint on Reported Victim (RV). While at the facility RV experienced a decline in his/her health. RV fell multiple times and became verbally and physically aggressive. A physician order was obtained for a ""soft"" restraint and a gait belt. The gait belt was used to restrain RV to his/her wheelchair. The licensee failed to obtain an appropriate assessment, complete orders, consent and complete documentation for a physical restraint as required. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA117099A,520983,AFH,3/27/2011,"On or about April 11, 2011 it was reported that Licensee failed to provide appropriate care for RV1. RP and/or RP's staff were not changing RV1 often enough causing a significant loss of personal dignity.",2,0,,, +CO14187,520983,AFH,9/24/2014,"Provider's son used to work in the AFH. In 2011, his background check was denied and he was told he could no longer provide care effective immediately. This was repeated to him and in 2011 and 2012, either he or the provider stated that he was working on getting the denial appealed or removed. In 2013, licensor had conversations with provider about son representing himself as working for provider and clarifying what was not allowed (including receiving information about residents). In August 2014, licensor again clarified that son could not provide care or have access to resident records. In September 2014, licensor discovered son does provider's books, wanted documentation on exception payments for Medicaid residents, directed provider not to speak with case manager about a resident until resident's daughter showed up, has demonstrated intimidation and hostility to state workers. Provider states he does not have access to records as they are with meds but did one time help her with a resident as he was falling. Provider claims he is not living in the home. She was cited for allowing him to work in the home with a denied background check and for violating resident rights to confidentiality. Sanction request for nonrenewal submitted to our office.",3,,,, +MV134380A,520993,AFH,9/10/2013,"On or about September 12, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim #1 (RV1). On 9/10/2013 RV1 experienced a seizure and was transported to the hospital. RV1's Salem hospital medical record dated 9/10/2013 noted that RV1's medication administration record (MAR) indicated that RV1 did not receive his/her medication the day of the seizure as the MAR had not been initialed as required. RV1 stated that he/she did receive his/her medication the day before and the day of the incident. Reported Perpetrator #2 (RP2) acknowledged that he/she did not initial the MAR but stated that all RV1's medications were administered the day before and the day of the incident. The licensee failed to keep the MAR current and accurate. The failure is a violation of Oregon Administrative Rule.",2,,,, +MV134380B,520993,AFH,9/10/2013,"On or about September 12, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #2 (RV2) and Reported Victim #3 (RV3) from inappropriate verbal comments. On 9/10/2013 RV2 was eating dinner in Reported Perpetrator #2's (RP2) room when RV2 was alerted to Witness #7's (W7) dog barking. RV2 went into W7's bedroom and discovered W7 experiencing a seizure. Emergency personnel was contacted. After emergency peronnel arrived RP2 yelled at RV2 to remove the dog from the room and used profanity toward RV2. RV3 stated that RP2 has ""yelled"" at RV3. The licensee failed to protect RV2 and RV3 from inappropriate verbal comments.",2,,,,Verbal/Mental abuse +CO15103,520993,AFH,5/27/2015,"During the course of inspection, the local licensing authority found a dismantled smoke alarm and falsification of medication administration records and activity records. Civil penalty for total amount of $750.00 issued.",3,750,,, +MM121302A,521002,AFH,9/20/2012,"On or about September 20, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RP acknowledged ""yelling"" at RV. RV stated that there were times when h/she did not feel safe due to RP. During a verbal argument RV called RP a bitch, RP threatened RV that if RV ever called h/her a bitch again RV would regret it. RV was uncomfortable at RP's. The licensee failed to protect RV from inappropriate verbal comments. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Verbal/Mental abuse +GP118100,521079,AFH,9/13/2011,"A report was received indicating that narcotic pain medications had been stolen from Resident #1 (RV1) on or about September 13, 2011. Reported Perpetrator #2 (RP2) admitted to taking approximately 11 pills. Law enforcement was contacted and RP2 was arrested. RP2's employment was terminated.",3,0,Not Substantiated,Substantiated,Financial abuse +CO12126,521079,AFH,11/21/2012,,3,0,,, +CO12035,521079,AFH,12/8/2012,"A monitoring visit was conducted at licensee_x001A_s adult foster home (AFH) on November 23, 2011. The licensor determined that caregiver #1 (SK), caregiver #2 (TB), and caregiver #3 (AS) did not have approved criminal record checks. Caregiver #1_x001A_s criminal record check expired on June 14, 2011 and caregiver #2_x001A_s criminal record check expired on May 26, 2011. There was no record that caregiver #3 had previously completed the criminal history process. Caregiver #1 (SK) and caregiver #2_x001A_s (TB) criminal record check approvals were not received until December 15, 2011 and caregiver #3_x001A_s (AS) criminal record check approval was not received until December 21, 2011. Licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,600,,, +CO13078,521079,AFH,6/7/2013,"Condition restricting admissions, requiring proper disposal of unused_x001A_medications, docuementation that meds_x001A_have been disposed and financial records.",0,0,,, +CO13094,521079,AFH,6/7/2013,Multiple issues: Two cgs working alone; failure to orient four cgs; failure to ensure 4 cgs had completed prep workbook; and allowing two individuals to clean around the home unsupervised.,3,1400,,, +GP133424B,521079,AFH,6/5/2013,"On June 6, 2013 and June 7, 2013, two staff members from the local licensing authority observed large amounts of narcotic pain and anti-anxiety medications stored in the kitchen, dining room and utility room of licensee_x001A_s adult foster home (AFH). Medications were found unlocked, visible and easily accessible. Department staff determined that much of the accumulated medications had been discontinued or outdated. Licensee acknowledged that all discontinued and unused medications should have been destroyed but that she had not taken the time to do so. Licensee failed to keep all medications locked in a central location and failed to properly dispose of all unused or discontinued medications. Licensee_x001A_s failure to provide a safe medication administration system is a violation of Oregon Administrative Rule.",3,900,,, +BR135113,521080,AFH,11/18/2013,"On or about November 18, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). RV is prescribed two blood pressure medication (Medication A and B). According to RV's medication administration record (MAR) medication A was not administered to RV on 09/09/13 through 10/13/13 and 11/10/13. According to RV's MAR medication B was not administered to the RV on 09/16/13, 17, and 18. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO15111,521080,AFH,6/8/2015,,3,600,,, +RB120823,521093,AFH,8/13/2012,"On or about August 13, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from theft of medications. RV was admitted to the facility in November of 2011. RV sustained a fall in January of 2012 and was prescribed narcotic pain medication due to the fall. RV moved from RP's facility in June of 2012. During this time it was discovered that RV was missing approximately 90 narcotic medication pills. The licensee failed to protect RV from theft of medication. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Financial abuse +RB135081,521093,AFH,11/13/2013,"On or about November 13, 2013, Witness #2 (W2) arrived to begin his/her shift. The previous caregiver was still on duty when W2 arrived. Because W2 was running late, the previous caregiver had placed Reported Victim #2's (RV2) medication in a labeled cup on the kitchen table. All residents in the adult foster home (AFH) have assigned seating at the table. Reported Victim #1 (RV1) was unaware that there had been a change in the seating. RV1 sat at the table where he/she normally sits. RV2's labeled medication was in front of RV1 when he/she sat down. RV1 believed these medications to be his/hers. RV1 ingested all of RV2's medications. It was not until RV2 stated that medications in front of him/her were not his/hers that W2 realized that RV1 had ingested RV2's medications. RV1 was then administered his/her own medication. W2 contacted RV1's primary care physician and the licensee (RP). W2 was instructed to monitor RV1's blood pressure and it if it went below 90 RV1 was to be taken to the hospital. RV1's blood pressure eventually declined below 90. Emergency personnel were contacted and RV1 was transported to the hospital for treatment. RP stated that normal protocol is that medications for all residents are set up in the afternoon into labeled medication cups then placed back into the medicine cabinet until dinner is served. After all the residents are sitting at the table eating, the medications are dispensed to the residents. RV1's medications include: blood pressure lowering #1, mineral supplement #1, blood pressure lowering #2, stool softener, mineral supplement #2. RV2's medications include: anti acid pill, cholesterol reducer, blood pressure lowering #1, blood pressure lowering #2, mood stabilizer, bone health supplement and pain medication. The licensee failed to provide a safe medication administration system which resulted in RV1's hospitalization. The licensee's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,350,,,Neglect +MF120299,521102,AFH,6/15/2012,"It was reported that on or about June 15, 2012, Licensee failed to provide an adequate medication administration system for Resident #1 (RV1). Licensee failed to follow physicians orders. Licensee continued to administer medication to RV1 that had been discontinued by his/her physician. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +AL117838,521114,AFH,7/19/2011,"Resident #1's (RV1) care plan dated March 6, 2011 indicated RV1 required assistance to sit, stand, and walk. On July 19, 2011, RV1 fell in the kitchen and sustained a skin tear to his/her arm and bruising on his/her back. On July 22, 2011, RV1 fell over the threshold of the AFH sliding glass door and hit his/her head on the vinyl floor. RV1 lacerated his/her head and had to be sent to the ER for surgery and sutures. RV1 fell again on July 24, 11 and re-injured their head wound. RV1 again was sent to the ER for treatment. RV1 was not receiving any assistance while ambulating during any of these falls. Licensee failed to follow RV1_x001A_s care plan resulting in multiple falls and injuries.",3,,,,Neglect +MV133690,521149,AFH,6/6/2013,"It was reported that on or before June 06, 2013, Licensee fialed to provide a safe environment for Resdent #1, Resident #2 and Resident #3 (residents). Licensee expected residents to do house hold chores and tried to get residents to accomplish physical activity. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee is substantiated.",2,,,, +MV147133,521149,AFH,5/10/2014,"It was reported that on or about May 10, 2014, Licensee failed to provide Resident #1 (RV1) with a prescribed medication and administered rv1 a medication that was not prescribed to RV1. Licensee's failures are a violation or Oregon Administrative Rules, Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV152042A,521149,AFH,7/8/2015,"It was reported that on or about July 8, 2015, Reported perpetrator #1 (RP1) failed to provide appropriate care to Resident Victim #1 (RV1). From May 5, 2015 through July 7, 2015, RP1 and Reported perpetrator #2 (RP2) repeatedly denied RV1 meals and snacks. RP1 and RP2's failures are a violation of AFH Oregon Administrative Rule, is considered neglect and constitutes abuse. Wrongdoing on the part of RP1 and RP2 was substantiated.",3,1200,Not Substantiated,Substantiated,Neglect +MV152042B,521149,AFH,7/8/2015,"It was reported that on or about July 8, 2015, Reported Perpetrator #1 (RP1) failed to protect Resident Victim #1 (RV1) from threats and humiliation. Reported Perpetrator #2 (RP2) called RV1 rude for making h/h medical transportation wait while R1 went to get h/h hat, and RP1 physically removed RV1's hat from h/h head as h/she was walking out the door, refusing to allow R1 to wear h/h hat to a medical appointment. RP2 asked RV1 if h/she liked walking around ""stinky"" when RV1 refused to bathe and RP2 humiliated RV1 by telling h/her he she was not acting like a Christian. Additionally Reported Perpetrator #4 (RP4) threatened to physically harm RV1. RP1's, RP2's and RP4's actions are a violation of AFH Oregon Administrative Rules, and is considered verbal/emotional abuse. Wrongdoing on the part of RP1, RP2 and RP4 was substantiated.",3,,Substantiated,Substantiated,Verbal/Mental abuse +MV152042C,521149,AFH,7/8/2015,"It was reported that on or about July 8, 2015, Reported Perpetrator #1 (RP1) failed to follow physician's orders for Resident Victim #1's (RV1) as needed (PRN) medications. RV1 was to recieve h/her PRN medication upon request according to physician's orders. Between 5/16/15 and 6/28/15, RP1, Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) refused to give RV1 h/her pain medication in accordance with physician's orders. On 5/16/15 RP1 substatuted RV1's PRN agitation medication for RV1's PRN pain medication after RV1 requested PRN pain medication. On 5/29/15 RP2 refused to provide RV1 a PRN agitation medication in accordance with physician's orders. On 6/06/15 RP1 refused to provide RV1 a PRN agitation medication in accordance with pysician's orders. RP1, RP2, and RP3's actions are a violation of AFH Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of RP1, RP2, and RP3 was substantiated.",3,,Substantiated,Substantiated,Neglect +MV152740,521149,AFH,9/4/2015,"Licensee failed to administer RV1's as needed (PRN) medications per physicians orders. On 7/24/2015 Resident #1 (RV1) requested a PRN for pain, which he/she was not administered. On 7/27/15, RV1 requested a PRN for anxiety, which he/she was not administered, and on 8/04/15 RV1 requested his/her PRN medication for pain which was not administered. Licensee tried to get RV1 to try alternative coping skills instead of providing RV1 his/her PRN medications as ordered by RV1_x001A_s primary care physician. The PRN parameters do not stipulate that RV1 must try alternative coping skills prior to the administration of his/her PRN medications. Licensee's failures are a violation or OAR's, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +MV153132A,521149,AFH,9/26/2015,"It was reported that on or about September 26, 2015, Licensee failed to provide as needed (PRN) medications as requested by Resident #1 (RV1). Licensee and Reported Perpetrator #2 (RP2) have continued to withhold RV1's PRN medications if RV1 requests them prior to RV1 having received his/her scheduled medications. Licensee's failure is a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of Licensee and RP2 has been substantiated.",2,,Substantiated,Substantiated,Neglect +MV153132B,521149,AFH,9/26/2015,"It was reported that on or about September 26, 2015, Licensee failed to protect Resident #1 (RV1) from harassment and failed to provide necessary care and services to RV1. Due to RV1 medical condition he she required special treatment as stated in his her behavioral support plan and also outlined in his/her care plan. Licensee engaged in conflict with RV1 as a result of RV1's not wearing his/her robe appropriately. Licensee antagonized RV1 by trying to get RV1 to hit her in the face. Licensee's failure is a violation of AFH OARs. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV153132C,521149,AFH,9/26/2015,"It was reported that on or about September 26, 2015, Licensee failed to follow Resident #1 (RV1's) care plan resulting in Resident #2 fearing for his/her safety. RV1 became agitated on September 25, 2015, and instead of following RV1's behavioral support plan and care plan facility staff hid from RV1 in Resident #2's (RV2) bedroom and locked him/her self in the bathroom to avoid RV1. Licensee failures are a violation of AFH OARs. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +DA116273,521150,AFH,11/6/2010,"On or about November 6, 2010, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). It was determined through interviews that RV2 was denied food due to RV2's behaviors. The licensee failed to provide a safe environment for RV2. The failure is a violation of Oregon Administrative Rule.",1,0,,, +HB128917B,521156,AFH,1/9/2012,"It was reported that on or about January 9, 2012, Licensee failed to provide a safe environment for Resident #1 (RV1). RV1 had a history of exit seeking and wandering, RV1 wandered from the facility on January 9, 2012 between 12:00 AM and 12:15 AM. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB146019,521156,AFH,2/6/2014,"It was reported that on or about February 6, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). On February 5, 2014, RV1 eloped from Licensee's home without Licensee's knowledge. Licensee's failures are a violation of Oregon Administrative Rules (OARs) is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +CO11140,521163,AFH,10/20/2011,"The licensor conducted a monitoring visit of the licensee_x001A_s Adult Foster Home on July 22, 2011. During the visit the licensor discovered that caregiver #1 did not have caregiver preparatory work book completed and was not qualified to be on duty. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. NOTE: email sent to AR to begin the aging process on 1/10/13",3,250,,, +CO12011,521163,AFH,7/22/2011,"The licensor conducted a monitoring visit at the licensee_x001A_s Adult Foster Home (AFH) on July 22, 2011. Caregiver #1 was on duty. During the visit the licensor confirmed that the licensee was not living in the AFH and there was not an approved resident manager or an exception for shift caregivers. The licensee_x001A_s failure to maintain qualifications of a licensee is a violation of Oregon Administrative Rules. NOTE: email sent to AR to begin the aging process on 1/10/13",3,250,,, +DA116286,521163,AFH,2/6/2011,"On or about February 6, 2011, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). It was determined through interviews and observations that RP placed unreasonable restrictions on RV. RP failed to provide appropriate care to RV. The failure is violation of Oregon Administrative Rule.",2,0,,, +DA121231,521163,AFH,9/10/2012,"On or about September 10, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to intervene when Reported Victim's (RV) condition changed. Witness #4 (W4) informed Witness #5 (W5) on 9/10/12 that RV had ""coffee ground emesis"". W5 directed W4 to take RV to the hospital. RV was not taken to the hospital. On 9/24/12 W5 was notified that RV was experiencing ""coffee ground emesis"" again. W5 directed that RV be taken to the hospital for assessment. RV was transported to the hospital for assessment on 9/25/12. The licensee failed to intervene when RV's condition changed. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Neglect +DA153523,521163,AFH,11/9/2015,"On or about November 9, 2015 Reported Perpetrator #1 (RP1) moved some belongings from the adult foster home. RP1 was not renewing the lease on the home and was removing items from the adult foster home such as pictures and games. RV1 confronted RP1 regarding items he/she was attempting to remove from the home that may not be his/hers to take. RP1 bent down and approached RV1 in his/her wheelchair and raised his/her voice at RV1. Following the incident RV1 indicated that RP1's verbal out burst made him/her feel small. Licensee failed to provide a safe and homelike environment and failed to treat RV1 with respect and dignity.",2,,,, +CO15260,521163,AFH,12/23/2015,Provider has a home with multiple caregivers working alone that are not qualified.,3,950,,, +CO15248,521177,AFH,12/4/2015,Failure to have an approved background check (Licensee),3,200,,, +CO13019,521193,AFH,7/19/2012,"An unannounced monitoring visit was conducted at licensee_x001A_s adult foster home (AFH) on July 19, 2012. The licensor determined that the sole caregiver on duty (KR) had not completed the Department_x001A_s Caregiver Preparatory Training Study Guide and Workbook prior to being left alone with residents. Licensee failed to have a qualified caregiver present and available in the AFH at all times, twenty-four hours per day, seven days per week. Licensee_x001A_s failure is a violation of Oregon Administrative Rules.",3,250,,, +AL118605A,521263,AFH,11/30/2011,"Licensee was observed on November 30, 2011 pushing Resident #1_x001A_s face and head and being very rough while shaving the resident. Resident #1 attempted to bury the right side of his/her head, likely due to a medical condition that made his/her face very sensitive to touch. Caregiver #1 stated _x001A_While the licensee was shaving Resident #1, the resident was screaming as if in pain. After licensee shaved Resident #1, the resident_x001A_s face was raw._x001A_ The facility failed to protect the resident from rough treatment. The failure is a violation of resident rights and constitutes physical abuse.",3,850,,,Physical Abuse +AL118813,521263,AFH,9/9/2011,"On August 30, 2011, Licensee received 120 tablets of narcotic medication for Resident #1. On September 9, 2011, Caregiver #1 counted the tablets remaining in the narcotics medication bottle and discovered 29 tablets were missing. Licensee acknowledged he does not keep narcotic counts and that approximately 20 caregivers had been working in the home since the time he received the narcotics. Additionally, licensee admitted he only locks narcotic medications and that all non-narcotic medications are unlocked. Licensee failed to prevent the theft of medications and failed to keep medications locked. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,400,,,Financial abuse +AL121785,521263,AFH,7/29/2012,"It was reported that on or about July 29, 2012, Licensee failed to provide a safe medication administration system for Resident #1 and Resident #2. On July 29, 2012, at approximately 11:00 PM Witness #3 (W3) discovered four tablets of Resident #1's narcotic medication missing from his/her medication drawer. Additionally, W3 found that Resident #2 had a medication card containing 30 tablets of one of Resident #2's medication was missing. Though Licensee has a policy requiring two staff members to count reconcile medications, staff didn't always follow the procedure. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +CO12095,521293,AFH,8/22/2012,"On August 22, 2012, the licensor made an unannounced visit to the licensee_x001A_s Adult Foster Home (AFH) in response to a complaint. The licensor received a complaint that the licensee left the AFH for two weeks and did not have qualified caregivers providing care to residents. The licensor confirmed that the licensee had been gone from June 17, 2012 through July 1, 2012, during which time unqualified caregivers provided care alone to the residents. The licensee acknowledged that she had exercised poor judgment, was aware that she could be in trouble and stated she accepts responsibility for her actions. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +GB121409,521293,AFH,10/24/2012,"On or about October 24, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #1 (RV1) and Reported Victim #2 (RV2). RP left on vacation on 6/17/12 and left RV1 with three unqualified caregivers. During RP's vacation, RV1 was left alone multiple nights. RP left RV1 and RV2 alone without a caregiver and left RV2 home alone without a qualified caregiver during the month of October, 2012. RP left RV1 and RV2 with W7 who was not a qualified caregiver. It was determined that the licensee failed to provide appropriate care to RV1 and RV2. The failure is a violation of Oregon Administrative Rules.",3,0,,, +CO11097,521296,AFH,6/15/2011,,2,250,,, +CO14059,521296,AFH,3/21/2014,Continued to care for Resident #1 whose decline resulted in becoming a Class 3 resident in a Class 2 home. No variance was requested prior to the licensor identifying the situation.,3,250,,, +NB146286,521296,AFH,3/5/2014,"Resident #1 (RV1) required full assistance with mobility and transferring. On or about July 19, 2012, progress notes for RV1 included that RV1 had some pressure points developing from being in bed so much. On or about July 26, 2012, RV1 had a pressure sore on his/her left heel. An entry from RV1_x001A_s home health agency dated September 4, 2012 indicated that it was dangerous for RV1 to be transferred without a hoyer lift. Witness #4 (W4) remembered that a health provider mentioned a hoyer lift for RV1 last year and W4 stated that the facility would have used it but it was never ordered so W4 figured it wasn_x001A_t needed. + + + +RV1_x001A_s facility progress note and home health agency note dated February 8, 2014, indicated that home health had visited with RV1 that day. It was identified that RV1 had pressure sores on his/her sacrum and both heels. The facility stated that they will keep him/her off of his/her back at all times and keep RV1_x001A_s heels off the bed using pressure relieving boots. A facility incident report also dated February 8, 2014 noted that during a transfer RV1 started yelling in pain and he/she was set down on the floor. The facility had to call 911 who dispatched emergency medical technicians to the AFH to put RV1 back in his/her bed. A home health agency note dated February 13, 2014 documented that the wound on RV1_x001A_s buttocks was now open. + + + +A supplemental order issued by home health on March 4, 2014 stated that the sacral ischial wound was at least a stage 3 with undermining and about 15% slough tissue at the base. Also on or about March 4, 2014, home health documented that RV1 needed two people to move him/her to reduce the friction on his/her wound and that RV1 should be lifted, not pulled. It was observed that there was only one caregiver on duty. + + + +Witness #1 (W1), Witness #2 (W2) and Witness #3 (W3) all reported that RV1 required two people to move him/her. The AFH was staffed with only one person per shift and in the absence of sufficient staff to meet the care needs of RV1 staff would slide RV1 to position him/her. RV1 described that the staff on duty would _x001A_pull_x001A_ on RV1 underneath his/her armpits and slide him/her to where facility staff wanted him/her. W3 reported that the sore on RV1_x001A_s coccyx had worsened due to RV1 being _x001A_dragged_x001A_ during repositioning as this method caused friction and would not allow the coccyx wound to heal. + + + +RV1 had pressure relieving boots and W2 reported that he/she had shown the AFH staff how to use the boots. However, when RV1_x001A_s physical therapist visited the AFH on March 5, 2014, the boots were not being used properly and RV1 was lying on his/her coccyx wound. W3 also witnessed times when RV1_x001A_s boots had been put on incorrectly which caused RV1_x001A_s wounds to worsen. W3 further stated that RV1_x001A_s boots were not used everyday which RV1 confirmed. W1 reported that RV1_x001A_s heels have had sores on them for at least a year. RV1 reported that his/her heels hurt and that RV1 had not been able to put any pressure on them for months. + + + +On or about March 7, 2014, home health identified a new stage one wound on RV1_x001A_s _x001A_left hip/upper butt area_x001A_. A reminder was given to the facility to turn RV1 every two hours with two people lifting him/her up in bed and _x001A_don_x001A_t drag_x001A_. + + + +A facility progress note dated on or about March 8, 2014 reflected that RV1 had developed another red spot on his/her buttocks and was getting darker and _x001A_very concerning_x001A_. + + + +During the course of the investigation that commenced on March 7, 2014, RV1_x001A_s latest care plan was reviewed. The care plan provided to the investigator was dated August 19, 2013. Care plans must be reviewed and updated every six months or as the resident_x001A_s condition changes. + + + +Licensee failed to take the necessary precautions to prevent the development and worsening of RV1_x001A_s wounds which caused RV1 unreasonable pain and discomfort for a prolonged period of time. Licensee failed to have sufficient staff to safely meet the 24-hour care needs of each resident. License failed to review and update RV1_x001A_s care plan every six months or as RV1_x001A_s condition changed. + + + +Licensee_x001A_s failures are a violation of resident rights, are considered neglect and constitute abuse.",3,450,,,Neglect +CO14101,521296,AFH,5/29/2014,Residents left alone with an unqualified (no background check) cg.,3,250,,, +BH118422,521301,AFH,11/4/2011,"On or about November 7, 2011, it was reported that the Licensee had failed to follow medical orders. Beginning November 4, 2011, Resident #1's (RV1) medical provider had ordered that RV1's pain be monitored four times daily using a pain scale. A review of RV1's records showed that RV1's pain level was assessed and recorded only once each day. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BH121740,521301,AFH,11/15/2012,"On or about November 15, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). It was determined that RV requested to be changed due to h/her incontinence. Reported Perpetrator #2 (RP2) informed RV that RV would have to wait until RP1 returned to the adult foster home. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV146601,521337,AFH,4/2/2014,"On or about April 3, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RP was aware of RV's history of falls prior to RV being admitted to the adult foster home (AFH). RV's care plan dated 3/16/14 notes that RV is a full assist with transfers and RV uses a walker and staff will be a standby at all times. Under night needs it notes RV mostly sleeps through the night, but needs assistance getting onto bedside commode and RV must wear a tab alarm to prevent any injury due to fall risk. Under behavior it states RV has mild confusion due to dementia. Witness #1 (W1) states that he/she was not able to get RV up off the floor by him/herself so he/she would contact emergency personnel for assistance. W1 notes that RV falls mostly during the night. RV fell eight times in two weeks. Emergency personnel was contacted six times in two weeks to assist staff for lift/transfer of RV. RP has a tab alarm in place. RV's progress notes indicate RV has the ability to turn off the tab alarm. RP placed a mesh side rail on RV's bed. The licensee failed to adequately care plan related to falls. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +MV150270,521337,AFH,2/15/2015,"On or about 2/17/15, APS received a complaint that the facility failed to provide appropriate care to RV. During the course of the investigation, APS determined that RV entered the facility on 2/5/15 and left the facility on 2/15/15 via ambulance. RV had a Foley catheter in place during his/her stay at the facility. Although RP2 was a caregiver at the facility, RP2 had not received catheter care training. The facility failed to provide adequate catheter care and failed to obtain or administer pain and bowel care medications to RV in a timely manner. On 2/15/15, ER staff noted that RVs catheter was dirty and RV was diagnosed with a UTI by an ER doctor. Facility's failure to provide adequate catheter care and failure to obtain or administer pain and bowel care medications to RV in a timely manner is a violation of resident rights, constitutes neglect, and is considered abuse.",3,400,Not Substantiated,Substantiated,Neglect +MF116288,521338,AFH,2/8/2011,"It was reported on or about February 8, 2011, that the Licensee failed to provide and adequate medication administration system. Resident #1 had a history of not taking his/her medication when administered and would stock pile/hoard medications. Resident #1 was admitted to the hospital as a result of consuming a handful of medication that he/she had managed to hide in his/her bedroom. Wrongdoing on the part of the Licensee was substantiated.",3,400,Substantiated,Substantiated,Neglect +CO13089,521338,AFH,6/14/2013,,3,450,,, +CO14011,521338,AFH,12/30/2013,"During an inspection on December 30, 2013, it was discovered that Licensee had an extension cord in place of permanent wiring in Resident #4_x001A_s bedroom. Licensee's failures are a violation of Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,250,,, +CO11014,521341,AFH,1/11/2011,,1,250,,, +KF116249C,521341,AFH,2/1/2010,"Resident #2 (RV2) was independent in his/her night needs. RV2 fell out of bed during the early morning of October 24, 2010 and was injured. Reported Perpetrator #2 (RP2) was sleeping in the living room while on duty and did not hear RV2 calling for help through his/her closed door. RV2 had to crawl to the living room to get RP2's attention.",2,0,,, +DA132275B,521367,AFH,1/28/2013,"On or about January 28, 2013, it was alleged that Reported Perpetrator (RP) failed to administer medication as ordered to Reported Victim (RV). W5 made a visit to the licensee's adult foster home to look for RV's false teeth. W5 was able to locate RV's false teeth under RV's bed. W5 also discovered ""8 or 9"" pills in an empty kleenex box. RV's medication administration did not reflect the missing medication. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14040,521367,AFH,2/26/2014,Letter of Withdrawal of License Condition #AFHCD14-007 sent to new provider Melissa Cuanas on 5/30/14.,3,0,,, +CO15003,521367,AFH,12/31/2014,"LICENSEE - MELISSA CUANAS / 517C request for non-renewal but no application materials were received prior to expiration of license. Betsy later received a complete packet which will now be processed as an ""initial"". Closed on 01/27/15.",3,,,, +CO15019,521367,AFH,1/7/2015,"Late renewal - license expired. Still providing care and move-out notices not given. + +Due to ""compensation"" being included in AFH rules, issue Warning Letter instead of CP.",3,,,, +OT164743,521378,AFH,2/22/2016,"It was reported that on or about 2/22/16, Licensee failed to care to Resident #1 (RV1). RV1 had a procedure performed and was prescribed a pain medication the same day. RV1 went without the pain medication from 2/22/16 until 2/24/16. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +AL133851,521392,AFH,4/22/2013,"On or about April 22, 2013, Resident #1 (RV1) was on the front porch of Licensee's adult foster home (AFH) holding onto the handrail. Witness #2 (W2) and Witness #3 (W3) heard RV1 screaming. W2 observed Reported Perpetrator #2 (RP2) strike RV1's forearms using his/her palms and then ""hit"" RV1 twice in the bicep using his/her elbows. W3 reported RV1 was screaming, ""Help, help, help"". RP2 acknowledged striking RV1's forearms in an attempt to release RV1's grip on the porch handrail and that he/she placed his/her arms under RV1's arms in order to drag RV1 backward into the AFH. RV1 was observed to have skin discolorations on his/her left and right arms and toes and an abrasion to his/her forearm. Facility failed to provide a safe environment for Resident #1. Licensee's failure is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Physical Abuse +CO11130,521408,AFH,8/18/2011,"The licensor conducted an inspection of licensee_x001A_s AFH on August 18, 2011. During the visit the licensor discovered that the smoke alarm located in the basement was not functional. The Licensee failure to provide a safe environment are a violation of Oregon Administrative Rules.",3,200,,, +CO12021,521408,AFH,1/18/2012,"On January 18, 2012, the licensor was notified that caregiver #1_x001A_s criminal record check expired 12/02/11 and caregiver #1 has been working in the licensee_x001A_s Adult Foster Home (AFH). The licensor contacted the licensee. During the phone call the licensee informed the licensor that caregiver #2_x001A_s criminal record check expired on 11/29/11 and caregiver #2 has been working in the AFH. A home visit was conducted by the licensor on January 18, 2012. During the visit the licensee admitted to the licensor that caregiver #1 works independently every Friday and Sunday from 7am-4pm, and caregiver #2 works independently 12am-10am four days per week. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",0,500,,, +OT150551,521408,AFH,3/1/2015,"On or about March 2, 2015, APS received a complaint that the facility failed to follow the Medication Administration Record (MAR) resulting in potential risk of serious harm. During the course of the investigation, APS determined that on March 1, 2015, at 8am, RP2 gave RV 5x the normal dose of RP2's medication. RV's doctor orders indicate that RV should receive 1mg of a particular medication 3x daily. Instead, RP2 gave RV 5 mg of the medication. RP2 had been distracted by another resident while administering RV's medication. The incident was reported to APS and RV was observed during the remainder of the day to ensure no adverse reactions. The facility also held the remaining dosages of the medication for the remainder of the day. Facility's failure to administer medication as ordered is a violation of Oregon Administrative Rule.",2,150,,, +OT150861,521408,AFH,3/21/2015,"On or around 3/23/15, APS received a complaint that the facility failed to provide appropriate medication administration system. During the course of the investigation, APS substantiated the following: RP2 worked the 3/21/15 shift when the incident occurred and it was RP2_x001A_s responsibility to administer medications. RP2 did not administer prescribed narcotic medication but signed the MAR and narcotic count sheet as having administered the medication and then lined through the entry with a side note indicating the medication was not given. RP2 gave p.r.n. medication for anxiety to RV for a reason that did not follow doctor orders/parameters and signed as having administered the narcotic count sheet on the wrong date. RP2 was aware of making wrong entries and stated he/she intended to correct the documentation later and falsely documented a medication as refused when the narcotic count sheet did not match the amount of narcotics on site. RP2 failed to notify the resident manager of the medication error and failed to follow proper procedures when administering medication. RP2_x001A_s failure is a violation of OAR and resident rights, is considered neglect, and is a form of abuse.",2,,Not Substantiated,Not Substantiated,Neglect +OT151513,521408,AFH,6/5/2015,"On or about June 8, 2015, Adult Protective Services received a complaint that RP failed to provide a safe and secure environment for RV. During the course of the investigation, APS determined the following: on 6/5/15 RV indicated a need to be changed due to a bowel movement. When RP2 discovered that RV had not had as much of a bowel movement as thought and RP2 told RV ""you lied"" and used his/her hand to strike RV on the buttocks area. RP2's actions were not welcomed; they did not cause bodily injury, physical pain, discomfort, or adverse reaction. RP2's actions were a failure to treat RV as an adult with respect and dignity. The facility failed to guarantee that an employee of the home did not violate resident's rights. This failure is a violation of Oregon Administrative Rule.",1,,,, +CO16008,521408,AFH,12/30/2015,Licensee removed two smoke alarms from required areas. CP sanction requested $500.00 CP granted.,3,500,,, +AL147123,521409,AFH,1/22/2014,"On or about January 22, 2014, Resident #1 (RV1) had all of his/her teeth extracted. The post care instructions issued by RV1's medical professional on January 22, 2014, included that RV1 was to be a diet that was ""not too hot and not too cold"" and to be dispensed antibiotic and pain medication three times per day. Witness #1 gave RP2 further clarifications about the after care, including that the pain medication was to be administered every 6-8 hours, ice should be applied to each side of RV1's face and RV1 should not be served hot liquids. RV1's Medication Administration Record for January 2014 indicated that RV1's medications were not administered until the morning of January 23, 2014. Reported Perpetrator #2 (RP2) served RV1 hot soup and RV1 took only one sip because it was too hot. Additionally, RP2 did not apply ice to RV1's face because the facility had no ice. + + + +During the course of the investigation, Reported Perpetrator #1 (RP1) stated RP2 had only been on the job for about two months and that RP1 had been a ""little concerned"" about RP2's abilities as a caregiver. The facility failed to administer pain medication and provide appropriate care and services that resulted in RV1 experiencing unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect, and constitutes abuse. The abuse has been apportioned to both Reported Perpetrator #1 and Reported Perpetrator #2.",2,,Substantiated,Substantiated,Neglect +AL154100,521409,AFH,12/29/2015,"RV2 was smoking on the facility porch at night. RV1 complained to RV2 about his/her smoking, and the two residents got into an argument. RV2 hit RV1 twice on the side of the head. Facility took RV1 to the hospital for a check, and no injuries or issues were found. RV1 stated RV2 hitting him/her ""just came out of nowhere,"" had not happened before, and RV2 later apologized. The facility was aware that RV1, when agitated, could be controlling of other residents' behaviors, and although RV1 meant well, other residents tended to ""take it the wrong way."" Facility agreed to update RV1's care plan to reflect RV1's behaviors when agitated",2,,,, +CO13028,521423,AFH,2/12/2013,"On February 7, 2013, an e-mail was sent to the licensee from the Department informing the licensee that caregiver VD did not have a cleared criminal records check. On February 12, 2013, a phone call took place between VD and the Department and it was disclosed that VD was the only caregiver on duty providing care. It was then verified that as of February 12, 2013, VD did not have a cleared criminal records check as required. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +GP121830,521455,AFH,12/5/2012,"On or about December 5, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from loss of property. Witness #1 (W1) was staying with Reported Perpetrator #2 (RP2) at the adult foster home. W1 observed RP2 handling RV's medication and observed where the key was kept to the medication cabinet. RP1 was notified that W1 was transported to the hospital due to an overdose of opioid medication. It was found that RV was missing 22 synthetic opioid pills. RV's opioid medication had been discontinued. W1 acknowledged to law enforcement that h/she stole 22 opioid pills that belonged to RV while RP2 was asleep. The licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights and constitutes abuse.",2,,,,Financial abuse +CO15048,521455,AFH,2/24/2015,Unqualified caregiver left alone with residents.,3,250,,, +CO14217,521480,AFH,8/27/2014,"At follow up visit on 8/25/14, the LLA determined that only one caregiver was on site and the other caregiver was not with a resident at a medical appt. (Licensee has special needs contract requiring 2 cg's on duty at all times unless 1 is with a resident at a medical appt.) On 8/27/14, licensor returned to the home and found two caregivers on duty. One cg did not have an approved background check. FOD and e-mail sent to LLA.",3,400,,, +MM116615A,521486,AFH,3/11/2011,"On or about March 11, 2011, Reported Perpetrator #2 (RP2) stated, within Resident #1's (RV1) hearing, that he/she wanted to punch Resident #1 in the mouth. This statement caused RV1 anxiety and fear.",2,0,,,Verbal/Mental abuse +MM116615B,521486,AFH,3/11/2011,"Resident #2 has care needs related to skin care, eating, and toileting that are not addressed on his/her service plan. As a result, the resident did not receive appropriate care and services.",2,0,,, +MM117287A,521486,AFH,6/15/2011,"On or about June 23, 2011 it was reported that Licensee failed to provide appropriate care. The Licensee failed to put in place appropriate intervention in RV's Service Plan when he/she refuses to shower. The Licensee failed to provide appropriate care to RV by not assisting RV when care is requested.",2,0,,, +WB132030,521486,AFH,1/3/2013,"It was reported that on or about January 4, 2013, Licensee failed to provide appropriate care for Resident #1. Resident #1 lacked of assistance with hygiene resulting in an infection. Resident #1 was transported to the hospital for treatment. After arriving at the hospital Resident #1 was observed to be un-bathed and smelling on urine. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV134882,521486,AFH,10/9/2013,"It was reported that on or about October 9, 2013, Licensee failed to provide a safe environment for Resident #1 (RV1), Resident #2 (RV2), Resident #3 (RV3), Resident #4 (RV4), and Resident #5 (RV5). Reported Perpetrator #3 (RP3) behaviors were verbally/mentally abusive towards residents. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +WB147385,521486,AFH,6/5/2014,"On or around June 6, 2014, Adult Protective Services (APS) received an allegation that the facility failed to provide a safe environment. RV2 yells, punches things, and makes hand gestures towards other residents. RV1 wants to fight RV2 in order to protect other residents due to RV2's aggression. RP was aware of RV2's behaviors prior to placement and is paid by the Department of Human Services to provide one on one care for RV2. RP has not hired a caregiver to provide such one on one care and did not provide an answer when questioned about this staffing plan. RV2 swung at RV1 because RV1 came into RV2's room and yelled at RV2. RP's failure to employ staff for one on one care when RP is paid to do so, places residents at risk of physical harm. RP's failure to provide a safe environment is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +WB147618,521486,AFH,6/25/2014,"RV1 was a resident of the adult foster home. Some residents of the AFH yell at and make fun of RV1. On June 7, 2014 RV1 was going into the house and another resident did not want him/her there and told RV1 to leave. On June 21, 2014 RV1 was walking by another resident and the other resident punched RV1 in the jaw and neck. On June 26, 2014 RV1 was getting a towel to use and W3 told RV1 not to drool all over all the towels, causing RV1 to become agitated. Once RV1 had calmed down the other residents began to call him/her names, which caused another outburst by RV1. The facility failed to provide a safe and home-like environment for all residents.",2,,,, +MS121552,521488,AFH,11/8/2012,"It was reported that on or about November 8, 2012, Licensee failed to protect Resident #1 from inappropriate physical contact. Resident #1 told Licensee how to give an injection to another resident at the facility and Licensee told Resident #1 not to intervene. Resident #1 began swearing and when he/she did not stop Licensee tapped and patted Resident #1's head. Licensee hit Resident #1 on the back of the head three times. Licensee's failures are a violation of Oregon Administrative Rules and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +MS152120,521488,AFH,7/17/2015,"It was reported that on or about July 17, 2015, Licensee failed to provide timely medical treatment. Licensee discovered that Resident #1 had developed a toe infection. Licensee did not seek medical attention for Residnet #1. Resident #1 complained of toe pain to Witness #2 so witness #2 took Resident #1 to the physician. It was discovered that Resident #1 had toe nail infectionsan both feet. Licensee's failure is a violation of AFH OAR, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +CO15153,521494,AFH,7/30/2015,"Licensee failed to have a qualified caregiver in the home 24/7 when the resident was in the home (LAFH), failed to meet the service interval of a fire extinguisher and failed to properly locate a carbon monoxide detector by resident bedroom.",3,400,,, +CO11150,521495,AFH,12/2/2011,,3,650,,, +MV129516,521495,AFH,3/15/2012,"During an investigation conducted on March 16, 2012, it was found that Licensee charged Resident #1 for services that he/she did not provide. Resident #1 was living in Licensee's Adult Foster Home (AFH) in February of 2011, Resident #1 became ill and was admitted to the local hospital in February of 2011. After being treated at the hospital, Resident #1 was then admitted into a nursing home for rehabilitative purposes. In February of 2011 Witness #1 (W1) arranged to reserve Resident #1's placement in Licensee's AFH, and agreed to pay a _x001A_bed hold fee_x001A_ to reserve Resident #1_x001A_s placement. W1 made payments to Licensee on Resident #1_x001A_s behalf from February 2011 until March 2012 to reserve Resident #1's placement. The total sum paid to Licensee during that time was $11,377.01. When attempting to re-admit Resident #1 into Licensee's AFH, Licensee indicated he/she had rented Resident #1's room in the AFH to another person approximately 6 months prior. Licensee's failures are a violation of AFH Oregon Administrative Rule, are considered financial exploitation and constitute abuse.",3,400,,,Financial abuse +CO15096,521495,AFH,5/15/2015,,3,250,,, +MV153148,521495,AFH,9/29/2015,"It was reported that on or about September 29, 20185, Licensee failed to maintain an adequate medication administration system resulting in documentation error. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +ES116226A,521522,AFH,1/26/2011,"On January 27, 2011, it was reported that Resident #1 had unusual financial activity identified on Resident #1's accounts. The investigation concluded that the Licensee failed to protect Resident #1 from financial exploitation.",2,0,,,Financial abuse +ES116226B,521522,AFH,1/26/2011,"On or about January 27, 2011, Resident #1 ran out of medications before anticipated based on Resident #1's prescription. The investigation concluded that approximately 140 narcotic pain medications were unaccounted for during the time period from November 5, 2010 through January 26, 2011. Licensee's failure to protect Resident #1 from financial loss was substantiated.",2,0,,,Financial abuse +ES116373,521522,AFH,2/11/2011,"Reported Perpetrator #2 (RP2) borrowed $2,500 from Resident #1 (RV1). Reported Perpetrator #1 (RP1) was aware that RP2 had not paid back RV1. Licensee failure to protect RV1 from financial expoitation was substantiated.",3,0,,,Financial abuse +ES116389,521522,AFH,2/7/2011,"On February 18, 2011, it was reported that Reported Perpetrator #1 (RP1) had allowed a Subject Individual (Reported Perpetrator #2) to live in the home without completing a Criminal Records Check. Licensee's failure to have an approved criminal records check on all Subject Individuals exposed residents to potential harm.",2,0,,, +ES1116225A,521522,AFH,1/1/2011,"On January 27, 2011, it was reported that Resident #1 did not always receive a special diet and at appropriate intervals. Licensee failure to provide proper nutrition was substantiated.",2,0,,, +ES1116225C,521522,AFH,1/1/2011,"On January 27, 2011, it was reported that the Licensee had failed to ensure information was correctly relayed between the medical specialist and the Licensee after each of Resident #1_x001A_s medical appointments. Resident #1_x001A_s physician ordered an antibiotic on March 3, 2011. It was determined through interviews and observations that the prescription was not filled. Licensee failure to follow a doctor_x001A_s order was substantiated.",2,0,,, +ES1116225D,521522,AFH,1/1/2011,"On January 27, 2011, it was reported that the Licensee had failed to provide adequate wound care services to Resident #1. Through interviews and observations, it was determined that the Licensee: 1) did not ensure Resident #1 attended clinic follow-up appointments on January 14 and and January 24, 2011; 2) a prescription for Neosporin was not obtained prior to administering the medication to Resident #1; and 3) a physician_x001A_s order for foam dressing was not immediately filled. Licensee_x001A_s failure to provide appropriate care and services was substantiated.",2,0,,, +CO15086,521545,AFH,2/4/2015,"On February 4, 2014, the licensor conducted an unannounced visit at the licensee_x001A_s adult foster home. Upon arrival caregivers CF and Cassandra Tolle were present. The licensor discovered caregiver Cassandra Tolle did not have a current approved criminal background check. Cassandra_x001A_s criminal background check was pending. Cassandra failed to have an approved background check as required. The licensee failed to provide a safe environment. + + + +While reviewing facility records the licensor found that caregiver Denise Smarez_x001A_s last approved criminal background check was 12/5/2013. The licensor verified Denise last worked on 2/4/2015. A caregiver on duty confirmed this. Denise Smarez failed to have an approved background check as required. The licensee failed to provide a safe environment.",3,400,,, +CO15040,521545,AFH,2/4/2015,"On February 4, 2014, the licensor conducted an unannounced visit at the licensee_x001A_s adult foster home. Upon arrival caregivers CF and CT were present. The licensor discovered caregiver CT did not have a current approved criminal background check. CT_x001A_s criminal background check was pending. CT failed to have an approved background check as required. The licensee failed to provide a safe environment. + + + +While reviewing facility records the licensor found that caregiver DS_x001A_s last approved criminal background check was 12/5/2013. The licensor verified DS last worked on 2/4/2015. A caregiver on duty confirmed this. DS failed to have an approved background check as required. The licensee failed to provide a safe environment.",3,400,,, +GP121388,521566,AFH,10/22/2012,"On or about October 8, 2012, Resident #1 was discharged from the hospital with orders to discontinue Medication #1 and Medication #2, and continue receiving Medication #3. Resident #1's Medication Administration Record (MAR) documents that the facility discontinued Medication #1 on October 8, 2012, as ordered; however, continued to administer Medication #2 through October 22, 2012 and discontinued Medication #3 on October 8, 2012. Facility failed to follow physician's orders regarding administration of Medication #2 and Medication #3. The failure is a violation of Oregon Administrative Rule.",2,0,,, +MS118577,521608,AFH,11/29/2011,"It was reported that on or about November 29, 2011, Licensee failed to protect Resident #1 (RV1) from threat of harm. A altercation broke out in the Adult Foster Home between Reported Perpetrator #2 (RP2) and Reported Perpetrator #1's (RP1) family member. The altercation became physical and RP2 pulled a knife on RP1's family member. All residents in the home were witnesses to the altercation. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",3,200,,, +MS129653,521608,AFH,4/2/2012,"On April 2, 2012, Resident #1 (RV1) took a fall in the presence of Witness #3 (W3), Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2), at the Adult Foster Home (AFH). RP2 yelled at RV1, _x001A_[RV1] get up!_x001A_ RV1 was on the floor after the fall and RP2 would not allow RP1 to assist RV1 in getting up from the floor, saying _x001A_no, no, [RV1_x001A_s] got to get up by [RV1_x001A_s] self!_x001A_ RP1 and RP2 did not assist RV1 in getting up from the floor and did not assess RV1 for injury after the fall. RV1 got up off the floor on his/her own and went into the bathroom. As a result of the fall RV1 did sustain an injury to his/her hand. Licensee_x001A_s failures are a violation of resident rights are considered neglect and constitute abuse.",3,400,,,Neglect +CO15065,521611,AFH,3/27/2015,,3,250,,, +CO15067,521632,AFH,3/27/2015,"During the course of the LLA's inspection, the LLA found a smoke detector in Licensee's bedroom with no battery. Mandatory civil penalty issued for removing the battery from required smoke alarm.",3,250,,, +CO11059,521644,AFH,4/20/2011,,2,250,,, +ES148258,521645,AFH,8/23/2014,"On or about August 25, 2014, APS received a complaint that the facility failed to protect RV1 from theft. During the course of the investigation, APS substantiated that RV1 had $50.00 in coins missing from the closet in his/her room. Although the facility provided a safe in RV1's room for RV1 to store the coins in, RV1 did not use the safe. RP1 reimbursed RV1 the $50.00. The police were notified. Facility failed to protect RV1 from theft, and thereby failed to maintain a safe and secure environment. Failure to maintain a safe and secure environment is a violation of resident rights, which is considered neglect, and constitutes abuse.",2,,,,Neglect +CO15129,521645,AFH,6/25/2015,"LLA contacted our office with issues of physical abuse, neglect, financial exploitation, and verbal/emotional abuse, as well as OAR medication violations for residents. Also, two residents have exception rates which require one on one care but neither are receiving it. Licensee has left residents alone on more than one occasion. Physical abuse included Licensee biting resident twice on inner thigh, holding resident down while caregiver punched in the head, and Licensee kicking in the face and giving resident bloody nose.",4,0,,,Physical Abuse +ES151668A,521645,AFH,6/21/2015,"On or about June 22, 2015, the Department received a complaint which alleged that the facility had failed to protect Resident #1 (RV) from rough treatment. The investigation determined that on June 21, 2015, the Licensee (RP1) had an altercation with RV. During the incident RP1 used a maneuver which resulted in both RP1 and the RV falling down onto a hard concrete surface. RP1's head ended up between RV's legs. RP1 bit RV on his/her inner thigh twice. Each bite was significant enough that it broke through RV_x001A_s skin and caused RV to bleed. Additionally, when Reported Perpetrator #2 (RP2) arrived at the scene, RP2 pounded on RV's head and neck. The conduct of both RP1 and RP2 is a violation of resident rights and constitutes physical abuse.",3,,Substantiated,Substantiated,Physical Abuse +ES151668B,521645,AFH,6/21/2015,"On or about June 22, 2015, the Department received a complaint which alleged the facility had failed to provide appropriate care and services for Resident #1 (RV). During the course of the complaint investigation, the adult protective services specialist determined that the Licensee (RP1) had failed to develop and document a care plan within 14-days of RV_x001A_s admission and had failed to provide sufficient staffing despite receiving an exceptional rate to provide one-on-one care for RV. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +ES151668C,521645,AFH,6/21/2015,"On or about June 22, 2015, the Department received a complaint which alleged the facility (RP1) had failed to protect Resident #1 (RV) from wrongful use of a restraint. The investigator for Adult Protective Services determined that on June 21, 2015, RP1 had used a leg sweeping maneuver to restrain RV on the ground. A review of resident records found no written order for the approved use of restraints. Licensee_x001A_s failure to have a written assessment and written order on file before a restraint was used is a violation of resident rights, is considered wrongful use of a restraint and constitutes abuse.",3,,Substantiated,Substantiated,Restraints +CO15193,521645,AFH,9/9/2015,"On or about June 25, 2015, the Licensee left residents unattended while taking another resident on a walk. Mandatory civil penalty.",3,250,,, +ES121107,521647,AFH,9/19/2012,"It was reported that on or about September 19, 2012, Licensee failed to provide appropriate care for Resident #1. Licensee left Resident #1 alone at the facility on several occasions. While Resident #1 was left alone he/she cut his/her foot. Licensee's failures are a violation of Oregon Administrative Rules and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +MF133355,521649,AFH,5/22/2013,"It was reported that on or about May 22, 2013, Licensee failed to provide a safe medication administrative system. On May 22, 2013, Resident #1 (RV1) was late to the dinning room table for breakfast. Licensee had set RV1's medication in a med cup and set them on the table unattended. Resident #2 (RV2) admitted to taking one of RV1's pills and flushing it down the toilet. Licensee's failures are a violation of Oregon Administrative Rules (OARs) is considered financial exploitation and constitutes financial abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Financial abuse +CO13098,521649,AFH,8/7/2013,"During a monitoring visit conducted on August 7, 2013, it was discovered that Licensee had left unqualified caregivers M.A. and G.A alone in his/her Adult Foster Home (AFH) on the afternoon of August 6, 2013, prior to completing the required Preparatory Training Study Guide and Workbooks. Licensee_x001A_s failure to have a qualified caregiver on staff 24 hours per day is a violation of AFH Oregon Administrative Rules (OARs).",3,250,,, +MS134030,521649,AFH,8/6/2013,"It was reported that on or about August 6, 2013, Licensee failed to provide appropriate care and services to the resident's of his/her Adult Foster Home. Licensee left the residents of his/her Adult Foster Home (AFH) alone with Reported Perpetrator #2 (RP2) who was unable to care for the resident's as he/she was found sleeping on the couch when the Investigator arrived. The Investigator observed RP2 to be difficult to arouse and observed RP2 to be in physical distress and verbally difficult to understand. During this time residents were unsupervised. Additionally, during this time Resident #1 (RV1) who is care planed to have His/her behaviors monitored became disorganized and confused. Licensee's failures are a violation or Oregon Administrative Rules, is considered neglect and constitutes abuse.",2,,,,Neglect +CO14103,521649,AFH,11/25/2013,Licensee failed to have a qualified caregiver present 24 hours per day as required. UPDATE: FOD Complete 7/29/14 and e-mailed AR requesting the Aging Process begin.,3,250,,, +MF152748,521649,AFH,9/9/2015,"On or about September 9, 2015, Adult Protective Services (APS) received a complaint that the facility failed to protect resident from physical harm. During the course of the investigation, APS was unable to determine whether or not RP2 kicked RV after RV asked RP2 to set up RV's portable oxygen tank on the wheelchair. RV ordered his/her own medications and, when it was delivered to the facility, both RV and RP2 wanted the medication bottle. In the process of RP2 taking the bottle of medications away from RV, the pills spilled ""everywhere"" onto the floor. RP2's failure to treat RV with respect and dignity resulted in contaminated medications. This is a violation of resident rights and is considered a violation of Oregon Administrative Rule.",2,,Inconclusive,Substantiated, +CO16067,521649,AFH,3/17/2016,"Local licensing authority sent a suspension request based on the following: history of abuse, preliminary report of abuse, threats to health, safety or welfare of resident (unqualified caregiver, no approved primary caregiver, unsanitary conditions in the home, fire life safety violations, medication administration violations and failure to meet operational standards of compliance (records violations, facility standards not maintained).",4,250,,, +AS118355,521669,AFH,10/24/2011,"On or about November 03, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from medication theft. It was determined that RV's narcotic medication was stored in a locked cabinet as required. RV's narcotic medication was discovered missing. RV went without RV's narcotic medication from October 24, 2011 to November 10, 2011. The licensee failed to protect RV from medication theft.",2,0,,, +AS117006,521669,AFH,5/17/2011,"On or about May 17, 2011, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) and RV do not get along. RP2 limited the amount of sugar and vanilla that RV consumed. RV does not have a diet limitation for sugar or vanilla. RP2 threatened to withhold RV's medication until the last minute that they are due. The licensee failed to protect RV from loss of dignity. The failure is a violation of Oregon Administrative Rule.",2,0,,, +CO12029,521671,AFH,2/15/2012,"On February 15, 2012, the licensor made a visit the licensee_x001A_s Adult Foster Home (AFH) in response to a complaint that smoke alarms were dismantled in the AFH. During the visit the licensor confirmed that the AFH common room and hallway did not have the required smoke alarms installed. The licensor also found that a required smoke alarm in Resident #1_x001A_s bedroom was not functional. The licensee failed to provide a safe environment. The licensee_x001A_s failures are a violation of Oregon Administrative Rules.",3,700,,, +HB129217A,521671,AFH,2/9/2012,"On or about February 9, 2012, it was reported that Reported Perpetrator #1 (RP1) failed to protect Reported Victim from inappropriate verbal comments. An argument took place between RP1 and RV. It was determined through interviews that RP1 raised his/her voice at RV and made inappropriate verbal comments toward RV. The licensee failed to protect RV from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rule.",2,0,,, +HB129217B,521671,AFH,2/9/2012,"On or about February 9, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim (RV). An argument occurred between Reported Perpetrator #2 (RP2) and RV. It was determined through interviews that RP2 was in RV's face screaming and yelling at RV. RP1 intervened and got in between RP2 and RV during the argument. As a result of the argument, RV felt scared and contacted the police. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rule.",2,0,,, +HB129217C,521671,AFH,2/9/2012,"On or about February 9, 2012, it was reported that Reported Perpetrator #1 (RP1) failed to maintain an adequate medication system for Reported Victim (RV). RV was ordered 40mg 2x daily blood pressure medication on 12/7/11. RP1 did not submit this order to the pharmacy until 1/16/12. RV's prescription for the blood pressure medication was refilled on 12/29/12 as 40mg 1x daily for 31 tablets. It was determined through interviews and observations that RV did not receive evening dose of medication from 1/1/12-1/13/12. RV did not receive morning or evening dose of blood pressure medication on 1/14/12 and 1/15/12. The licensee failed to provide a safe medication administration system for RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +SV117189B,521677,AFH,6/6/2011,"On April 1, 2001, RV's physician changed a medication from PRN to QID. This medication was properly dispensed through April 2011. The May MARS provided by the pharmacy did not reflect the new scheduled dosage. RP provided the medication to RV as written on the MAR (PRN), instead of as ordered by the physician (QID). That continued through June 10, when the error was pointed out to RP, and RP resumed the correct scheduled administration.",1,0,,, +AS149252,521681,AFH,11/16/2014,"On or about November 17, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from rough treatment. RV exhibits behaviors that can be combative and aggressive toward caregivers. RV's careplan dated 8/5/14 notes that when RV exhibits behaviors caregivers are to offer resident a ""distraction such as a magazine, cup of coffee, turning on music; call family and request they visit or staff to give phone to resident to speak to family; Encourage resident to socialize w/other residents and participate in weekly field trips; Reward client for calm behavior."" On the date of the incident RV was being combative toward Witness #1 (W1) and Reported Perpetrator #2 (RP2). W1 observed RP2 strike RV with a closed fist back hand with h/h right hand just under RV's left eye. Due to RV's condition RV did not have the ability to express if he/she was in pain.",3,,Not Substantiated,Substantiated,Physical Abuse +MV117239,521683,AFH,2/1/2011,"On or about February 2011 through March 2011, Licensee failed to protect Resident 1 from financial exploitation. Licensee accepted two medication deliveries for Resident 1 after the resident had moved from the adult foster home. Licensee disposed of the medications rather than returned them to the pharmacy.",3,300,,, +Co11144,521683,AFH,10/6/2011,"A monitoring visit was conducted at the licensee_x001A_s Adult Foster Home (AFH) on October 6, 2011. The licensor discovered that caregiver #1 was not qualified to be working in the AFH. Caregiver #1 was working in the AFH without an approved Criminal Records Check specific to the licensee_x001A_s home. The licensee_x001A_s failure to ensure a safe environment is a violation of the Oregon Administrative Rules (OARs).",3,250,,, +MV120566B,521683,AFH,7/16/2012,"It was found that on or about July 16, 2012, Licensee failed to maintain an adequate medication system. Licensee had initialed Resident #1's medication administration record as though he/she was getting his her medication when Resident #1 was in the hospital. Licensee's failure is a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO14017,521683,AFH,1/2/2014,"Licensee financially exploited Resident #1, Licensee's failures are a violation of Oregon Administrative Rules (OARs) is considerd financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,0,,,Financial abuse +MV135446A,521683,AFH,12/10/2013,"It was reported that on or about December 10, 2013, Licensee failed to provideproper care, services and treatment for Resident #1 and Resident #2. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV135446C,521683,AFH,12/10/2013,"It was reported that on or about December 10, 2013, Licensee failed to follow physicians orders for Resident #2. Licensee was not administering Resident #2 and Resident #3's medications as prescribed. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV145731,521683,AFH,5/24/2013,"It was reported that on or about May 24, 2013, Licensee failed to protect Resident #1 from financial exploitation. On May 24, 2013 Licensee made a $630.27 purchase to a clothing retailer through an account belonging to Resident #1. Licensee's failures are a violation of Oregon Administrative Rules, is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,,,Financial abuse +MV145732,521683,AFH,11/23/2013,"On or about January 2, 2014, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from financial exploitation. RV2 wrote a check to RP for $3500. RP indicated that he/she would use the money to retain an attorney for RV2. RP did not retain an attorney for RV2. RV2 wrote a check a check to RP for $2400 as RP indicated he/she would need to build a wheelchair ramp prior to admitting RV2 into the adult foster home. RP did not build a ramp with the $2400. Law enforcement was contacted. RP was arrested for criminal mistreatment 1 and theft 1 by deception. The licensee failed to protect RV1 and RV2 from financial exploitation. The failure is a violation of resident rights and constitutes abuse.",3,,,,Financial abuse +CO16071,521701,AFH,3/15/2016,,3,250,,, +FL121513,521706,AFH,11/3/2012,"On or about November 3, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. RP1 took RV to church on 11/3/2012. After the service RV was transported back to the adult foster home (AFH) by Complainant #1 (C1) without RP1's knowledge. RP1 waited for RV at the church after the service for an extended period of time. Upon arrival at the AFH, Reported Perpetrator #2 (RP2) scolded RV for allowing C1 to take RV back to the AFH and not notifying RP1. As a result, RV was fearful of RP2 and believed RP2 was going to hit RV.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +CO11052,521796,AFH,2/9/2011,,2,250,,, +OT146293,521796,AFH,4/4/2013,"On or about April 5, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). Witness #6 (W6) discovered that RV had multiple anti-anxiety medication pills missing. RV's medication administration record for the month of March 2013 was illegible and was marked over and through. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Financial abuse +JG120284,521801,AFH,2/22/2012,"It was reported that on or about February 22, 2012, Licensee failed to maintain an adequate medication system resulting in loss of medications. On February 22, 2012 it was discovered that Resident #1 had 31 narcotic medication tabs missing, Resident #2 had 21 narcotic medication tabs missing and Resident #3 had a bottle of liquid narcotic medication that had gone missing. Licensee was unable to determine what had happened to the medications. Licensee's failures are a violation of Oregon Administrative Rules, is considered financial exploitation and constitutes abuse.",2,0,,, +JG145595,521801,AFH,6/22/2012,"It was reported that on or about June 22, 2012, Licensee failed to maintain a secure environment for Resident #1 (RV1) and Resident #2 (RV2). RV1 and RV2 had money go missing while under the care of Licensee in the month of June 2012. Licensee determined the money went missing while Reported Perpetrator #2 (RP2) was on duty but was unable to identify who took the money. Licensee's failures are a violation of Oregon Administrative Rules. The theft of RV1 and RV2's money is considered financial exploitation and is considered abuse. Abuse has been apportioned to an unidentified individual in this case.",2,,Not Substantiated,Substantiated,Financial abuse +MS149243,521811,AFH,11/14/2014,"On or about 11/14/14, APS received a complaint that the facility failed to provide resident with an adequate medication system. During the course of the investigation, APS substantiated the following: RV is scheduled a prescribed pain medication patch every 48 hours. RP2 did not administer prescribed pain medication patch on 11/10/14. RP2 did not consult with the doctor in regard to the missed dose and waited until the next scheduled time to place the prescribed pain medication patch (on 11/12/14). RP2 failed to follow doctor orders and thereby failed to provide a safe environment for RV. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +CO15109,521811,AFH,6/5/2015,"Provider has repeat issues regarding medications, qualified caregivers, and resident safety. LLA requested both condition and civil penalty.",3,250,,, +MV164490,521838,AFH,2/2/2016,"It was reported that on or about February 2, 2016, Licensee failed to Protect Resident #1 from rough treatment. Wrongdoing on the part of Reported Perpetrator #1 and #2 has been substantiated.",2,,Substantiated,Substantiated,Physical Abuse +RB121369B,521878,AFH,10/4/2012,"Resident #1 was prescribed multiple medications. When Resident #1 moved from licensee's adult foster home, Resident #1's family member was given a list of Resident #1's medications and administration instructions. During a comparison of Resident #1's pharmacy prescription summary, his/her October 2012 Medication Administration Record (MAR), and the list provided to the family, it was determined there were a total of 10 medication inconsistencies. The facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",0,0,,, +CO14234,521878,AFH,11/12/2014,Licensee allowed unqualified caregiver to work in the home alone. Caregiver did not have an approved background check.,3,250,,, +CO11099,521888,AFH,7/13/2011,,2,250,,, +KF129928,521888,AFH,4/30/2012,"It was reported that on or about April 30, 2013, Licensee failed to provide Resident #1 (RV1) with adequate care and supervision. On two out of three visits when the investigator arrived there was no adult in the Adult Foster Home (AFH) with RV1. Licensee's personal belongings did not appear to be in the AFH as he/she had to go next door to get a jacket. Licensee admitted that he/she leaves RV1 alone while he/she goes next door to prepare meals for RV1. Licensee's failures are a violation or AFH Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",3,250,,, +GP117937,521905,AFH,9/5/2011,"On or about September 9, 2011, a report was received alleging the Licensee had failed to provide a safe environment for Resident #1 (RV1). The investigation determined that on or about September 5, 2011, RV1 had become agitated and was taken back to his/her room by the Licensee in order to avoid disrupting the other residents. Physical contact between Licensee and RV1 occurred. RV1 was later observed to have skin discolorations on RV1's right arm. Wrongdoing on the part of the licensee was substantiated.",2,0,,, +GP117937A,521905,AFH,9/5/2011,"Resident #1 has a history of agitation at dinnertime and was care planned to be taken to his/her room when his/her behaviors disturbed the other residents. On September 5, 2011, Resident #1 began arguing with the other residents. While licensee was wheeling Resident #1 back to his/her bedroom, Resident #1 locked the brakes on his/her wheelchair. When the licensee reached down to unlock the brakes, Resident #1 raised up his/her hands to stop the licensee. Licensee acknowledged that licensee grabbed Resident #1's arms. Resident #1 was later observed to have skin discolorations on his/her right arm. The licensee failed to protect Resident #1 from rough treatment. The failure is a violation of resident rights and constitutes physical abuse.",2,0,,,Physical Abuse +CO11109,521921,AFH,8/11/2011,Licensee failed to maintain substantial compliance with licensing rules since initial license issued in 2010. Licensee failed to maintain financial solvence and does not have the resources necessary to cover two months of operating expenses. Preliminary information indicates that Licensee isolated and verbally and financially abuse a resident. Licensee's actions demonstrate she does not possess the good judgment deemed necessary by the Department to operate an adult foster home.,3,0,,, +MS117435B,521921,AFH,7/13/2011,"Resident #1had a chronic skin condition that required the use of an ointment. The order for the ointment stated that it was to be administered twice daily with no stop date. The order was not for PRN administration. After the resident was admitted, his/her skin condition improved so Licensee discontinued using the ointment. On or about 7/13. 2011 it was determined that the resident's skin condition had flared up again. Licensee was not aware of the new skin problem.",2,0,,, +MS117435C,521921,AFH,7/13/2011,Resident #1 had a physician order for an ointment to treat a chronic skin issue. The oinment was to be administered twice a day. On July 14 it was noted that the resident's medication administration record showed that the ointment had been administered twice daily from July 1 through July 13. Licensee said the resident does not always need the ointment so it is not always used. Licensee indicated it had not been used in a long time.,2,0,,, +MS117435D,521921,AFH,7/13/2011,"Resident #1 had an order for a nutritional supplement to be administrated every 8 hours PRN. His/her medication administration order indicated that the supplement had been given to the resident once daily from July 1 though July 13, 2011. However, there was no supplement in the home and the Licensee acknowled that the supply had been out for at least a week.",2,0,,, +MF118239A,521921,AFH,10/18/2011,"On or about October 18, 2011, a report was received that alleged the Licensee (RP) had failed to protect Resident #1 (RV) from financial exploitation. It was determined that RV had purchased food that RP served to everyone in the facility. RV had spent his/her own money to rent a carpet cleaner. RP accepted gifts of a hand blender and crock pot from RV. Wrongdoing on the part of the Licensee was substantiated.",3,0,,,Financial abuse +MS117801,521921,AFH,8/23/2011,Each month Resident #1's representative sends Reported Perpetrator (RP1) $152 to disburse to Resident #1 for the amount of his/her monthly personal incidental funds (PIF). Resident #1 stated he/she did not usually spend the entire amount each month and should have some money saved up. The money Resident #1 had saved up cannot be accounted for. The facility failed to maintain any financial records listing all receipts for and disbursements to Resident #1. The failure is a violation of Oregon Administrative Rule.,2,0,,, +ES105692A,521942,AFH,11/17/2010,Licensee allowed Resident #1 to remain in his/her bed clothed only in a urine-soaked pajama top and incontinence garment and without any bedding or blankets. The window was open and the temperature outside was in the 40s. Licensee failed to provide appropriate care or to treat the resident with respect and dignity.,2,0,,, +ES105692C,521942,AFH,11/17/2010,"Licensee failed to report Resident #1's frequent refusal to eat, drink or take medications and weight loss to Resident #1's physician in a timely manner.",2,0,,, +ES116552,521942,AFH,3/17/2011,"On or about March 18, 2011 it was reported that RP1 was not documenting RV's CBG readings at the time taken. Many of RP1's CBG readings documented did not match the readings that were stored in RV's glucometer. RP1 did not verify CBG readings done by W1's glucometer against RV's gluometer. RV's CBG levels were sent to W3 who made decisions based upon the inaccurate figures RP1 documented.",2,0,,, +ES118478,521942,AFH,10/1/2011,"On or about October 1, 2011, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from financial exploitation. It was determined that RV1's wallet was taken from RV1. RV1 had money in RV1's wallet when it was taken. The wallet was later recovered with no money inside. RV2's pain medication went missing around September, 2011. The licensee was notified of RV2's missing medication on November 17, 2011. The licensee failed to protect RV1 from financial exploitation resulting in RV1's loss of funds. The licensee failed to protect RV2 from financial exploitation resulting in a loss of medication. The failures are a violation of resident rights and constitutes abuse.",2,0,,,Financial abuse +EN132073B,521993,AFH,6/26/2012,"On or about June 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), Reported Victim #5 (RV5) and Reported Victim #6 (RV6) from inappropriate verbal comments. Witness #3 (W3) stated that Reported Perpetrator #4 (RP4) would ""holler"" at RV3. Reported Perpetrator #3 (RP3) acknowledged yelling and raising h/h voice at RV5. The licensee failed to protect RV3 and RV5 from inappropriate verbal comments. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Verbal/Mental abuse +EN132073D,521993,AFH,6/26/2012,"On or about June 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), Reported Victim #5 (RV5), and Reported Victim #6 (RV6) from involuntary seclusion. RV2 witnessed Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) put RV1 in bed when RV1 expressed that h/she did not want to. During one incident Reported Perpetrator #4 (RP4) disliked the comment RV2 made about a meal. RP4 told RV2 to ""go to your room and stay there"". RV2 felt that h/she had to go and was afraid of what would happen if h/she didn't go. W2 stated that RV2 was not allowed to watch television in the living room in the evenings and was to remain in h/h bedroom. The licensee failed to protect RV1 and RV2 from involuntary seclusion. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Involuntary Seclusion +EN132073E,521993,AFH,6/26/2012,"On or about June 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), Reported Victim #5 (RV5), and Reported Victim #6 (RV6) from rough treatment. It was determined that RV2 heard RV1 yell ""don't make me do that, please, not now""! RV2 also heard RV1 say ""please don't squeeze so hard, it hurts"". Witness #1 (W1) stated that RP2 ""is rough with the residents"". The licensee failed to protect RV1, RV2, RV3, RV4, RV5 and RV6 from violation of resident rights. The failures are a violation of Oregon Administrative Rules.",2,0,,, +EN132073F,521993,AFH,6/26/2012,"On or about June 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), Reported Victim #5 (RV5), and Reported Victim #6 (RV6). Reported Perpetrator #2 (RP2) acknowledged that on multiple occasions RV4 went without h/h narcotic pain medication for a day or two. Witness #2 (W2) stated that on one occasion RP2 had W2 give one of RV2's laxitive medications to RV4 and RV5. W2 also stated that on or about February 2012 when RV1 returned back to the adult foster home (AFH) from the hospital with a heal sore RP2 insisted on treating the sore with medication that was brought from RP2's house without a physicians order. W2 witnessed RP2 take medication from a drawer from past residents and injest them. W2 witnessed RP2 take a prescription container from the AFH. Witness 3 (W3) stated that pills that are outdated or discontinued are stored in an unlocked drawer in the AFH. The licensee failed to provide a safe medication administration system for RV's. The failures are a violation of Oregon Administrative Rules.",2,0,,, +EN132073G,521993,AFH,6/26/2012,"On or about June 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim #6 (RV6). Reported Perpetrator #2 (RP2) acknowledged that RV6 was left on a bench outside a grocery store alone for approximately 20-30 minutes while a caregiver went in to purchase groceries. RV6's care plan dated 1/6/2011 indicates that RV6 will get lost if alone while out in the community and RV6 must always be accompanied. The licensee failed to provide a safe environment for RV6. The failure is a violation or Oregon Administrative Rules.",3,0,,, +EN132073C,521993,AFH,6/26/2012,"On or about June 26, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #3 (RV3) and Reported Victim #4 (RV4) from financial exploitation. RV3 was missing clothes after Reported Perpetrator #2 (RP2) cleaned RV3's room without RV3's permission. The licensee failed to protect RV3 from financial exploitation. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Financial abuse +NB132472A,521995,AFH,1/27/2013,"On or about January 27, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #1 (RV1). RV1 was admitted to the hospital on 2/16/13 due to an alleged fall. During the visit it was discovered that RV1 had bruising and a bump on h/her face and was in significant pain. It was determined RV1 fell on 1/27/2013. As a result of the fall RV1 sustained significant bruises and a large bump on h/her face. RP failed to intervene when RV1's condition changed. The failure is a violation of Oregon Administrative Rules.",2,0,,, +NB132472B,521995,AFH,1/27/2013,"On or about January 27, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). It was determined RV1 had increased wandering and falls. RP would often not hear or respond to requests for assistance at night for RV1 and RV2. RV1 and RV2 would frequently have verbal altercations. RP did not care plan around the verbal altercations. The licensee failed to provide a safe environment for RV1 and RV2. The failure is violation of Oregon Administrative Rules.",2,0,,, +NB132472C,521995,AFH,1/27/2013,"On or about January 27, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1). It was determined that RV1 had been prescribed an as needed medication to help decrease wandering during the night. RP was dispensing this medication regularly. RP did not dispense the medication on 1/27/2013 when RV1 fell which resulted in significant bruising. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14069,522009,AFH,3/19/2014,CP for unqualified and unapproved RM allowed to work in the home.,3,250,,, +NW149121,522041,AFH,10/17/2014,"The Adult Foster Home Complaint Investigation #NW149121, initiated on October 17, 2014 and attached hereto and incorporated into this notice by reference, substantiated the following: + + + +On or about October 17, 2014, the Department received a complaint which alleged the facility had failed to provide a safe environment for Resident #1 (RV). APS substantiated that Reported Perpetrator #2 (RP2) lifted RV out of his/her wheelchair and placed RV on the floor when RV_x001A_s conduct had displeased RP2. RV was unable to move from that location. Witness #2 (W2) reported that RV had cried while on the floor, and that RP2 laughed at RV while he/she was on the floor. RP2 did not pick RV up from the floor until RV apologized to RP2 multiple times. RP2 acknowledged to the investigator that he/she knew it was wrong. + + + +Also during the course of the investigation, it was determined that RP2 dropped a box of briefs down on RV_x001A_s stomach; sprayed yellow paint onto RV_x001A_s forehead and hair; poured a glass of water onto RV_x001A_s head because he/she would not drink water; twisted the arm of RV; slapped RV on the head with a piece of cardboard; placed RV on a wooden chair and pushed RV into the table hard enough that food fell to the floor; and sprayed a bug killer in resident rooms while the residents were sleeping. RP2_x001A_s conduct constitutes physical abuse, emotional abuse, involuntary seclusion and neglect as defined in Oregon Administrative Rule 411-020-0002(1)(a), (b)(A), (d) and (g)(A). + + + +Licensee failed to provide sufficient oversight to staff; failed to provide a safe environment for RV and failed to ensure the provision of appropriate care and services for RV. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +NW149123,522041,AFH,10/17/2014,"On or about October 17, 2014, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV1), Resident #2 (RV2), Resident #3 (RV3) and Resident #4 (RV4) from inappropriate verbal comments. + + + +During the course of the investigation, RV1 reported that Reported Perpetrator #2 (RP2) had accused RV1 of not having a broken collar bone and was told by RP2 that he/she was _x001A_faking_x001A_. RV1 also reported that RP2 yelled and complained about what RP2 had to do for the residents at Licensee_x001A_s (RP1) adult foster home (AFH) and complained about how much money it took to operate the home. RV1 also stated that RP2 threw rocks at his/her family member_x001A_s car and screamed at them loudly. RV1 felt very uncomfortable around RP2. Witness #1 (W1) documented that on August 23, 2014, W1 had been ready to assist RV1 with a bath but RP2 made RV1 angry when he asked if _x001A_Baby Huey_x001A_ was going to take a bath today. W1 reported that RV1 asked for _x001A_bibs_x001A_ when he/she was eating. On or about August 30, 2014, RP2 told RV1, _x001A_I_x001A_m going to teach you how to not be a slob_x001A_. RP2 then shoved the bib under the RV1_x001A_s plate, picked up a spoon and pushed the food onto the bib and said, _x001A_See, that_x001A_s how you do it!_x001A_ + + + +RV2 reported that RP2 called him/her a _x001A_spoiled brat_x001A_ and referred to RV2_x001A_s weight by saying he/she had a _x001A_Buddha tummy_x001A_. RV2 also recounted an incident when he/she did something that RP2 didn_x001A_t like and RP2 lifted him/her out of RV2_x001A_s wheelchair and set RV2 on the floor. W1 reported that RP2 left RV2 there until RV2 apologized to RP2 several times. W1 who was present for the incident also stated that RV2 was crying while on the floor and that RP2 had laughed at RV2. On or about August 14, 2014, RV2 did not want to drink water, only coffee. RP2 told RV2, _x001A_Alright dumbass, just kill yourself_x001A_ and then poured water on RV2_x001A_s head. Additionally, W1 documented that on or about August 9, 2014, RP2 placed RV2 into a wooden dining chair and pushed him/her into the table hard enough that food got knocked onto the floor. RP2 then asked RV2, _x001A_Are you a [gender] or a pig?_x001A_ + + + +RV3 stated that on January 13, 2015 he/she went to find food, RP2 yelled at him/her stating that RV3 could not have any food, he called him/her a _x001A_big fat pig_x001A_. Witness #3 (W3) reported that he/she was present when RP2 made remarks about RV3 being overweight. RV3 additionally reported that he/she was aware that RP2 told the caregiver that lives in a trailer on the property that he/she should not flush tampons down the toilet but instructed him/her to save them because RP2 was going to squeeze them out, tie the used products together and make a necklace for RV3. RV3 also reported that RP2 had yelled at him/her and he/she felt threatened and scared when RP2 told RV3 that he had _x001A_no idea what I_x001A_m capable of doing to you_x001A_. + + + +Additionally, W1 supplied the investigator with records that documented when W1 had heard RP2 use the word, _x001A_Bitch_x001A_ when speaking directly to RV2, RV3 and RV4 on multiple occasions in July 2014 and August 2014. + + + +The investigation concluded that RP2 used derogatory terms when referring to residents and made demeaning remarks to residents which resulted in RV1, RV2 RV3, and RV4 experiencing fear, unreasonable emotional discomfort and loss of personal dignity. RP2_x001A_s conduct constitutes verbal and emotional abuse as defined in Oregon Administrative Rule 411-020-0002(1)(d). + + + +Licensee failed to provide sufficient oversight to staff; failed to provide a safe environment for all residents, failed to provide a home-like environment for all residents and failed to ensure the provision of appropriate care and services for all residents. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Verbal/Mental abuse +NW152113A,522041,AFH,1/12/2015,"On or about January 12, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV) from derogatory comments made to or about RV. + + + +During the course of the investigation, RV reported that Reported Perpetrator #2 (RP2) had called him/her a _x001A_big fat pig_x001A_ when RV wanted something to eat. Witness #1 (W1) stated that he/she was present when RP2 had made remarks about RV being overweight. Witness #5 (W5) reported that RP2 referred to RV_x001A_s room as a _x001A_pigsty_x001A_ and called RV a _x001A_slob_x001A_. Additionally, W5 had heard RP2 tell RV that _x001A_you_x001A_re just nasty_x001A_. W5 added that RP2 referred to RV as a _x001A_demon child_x001A_. At times, RP2_x001A_s comments were made in front of others, including other residents. + + + +RV reported to the adult protective services specialist that RP2 yelled at him/her repeatedly and _x001A_messes with me mentally_x001A_. RP2 would also tell RV about how _x001A_pissed off_x001A_ and angry RP2 was with RV. RV was afraid of what RP2 could do to him/her. + + + +Witness #4 (W4) reported that when he/she provided transportation for RV, RP2 stated, _x001A_Now my day just got a little better_x001A_ [because RV was going out for a while]. W4 and W5 also reported that RP2 would make fun of the clothes RV obtained from a local resource. + + + +RP2 shared residents_x001A_ personal and confidential information, including diagnoses and the disease processes/treatments to other residents and outside individuals. W5 witnessed RP2 communicating this information in person and via phone conversations. RV indicated that RP2 referred to residents as _x001A_bitches_x001A_. W5 also reported that RP2 had yelled at him/her a number of times in front of the residents. These interactions upset the residents who witnessed them. + + + +The investigation concluded that RP2 used derogatory terms when referring to RV and made demeaning remarks directly to RV which resulted in RV experiencing fear, unreasonable emotional discomfort and loss of personal dignity. RP2_x001A_s conduct constitutes verbal and emotional abuse as defined in Oregon Administrative Rule 411-020-0002(1)(d). + + + +Additionally, based on a preponderance of interview statements, it was determined that Licensee called RV _x001A_lazy_x001A_ which resulted in loss of personal dignity and emotional discomfort to RV. Licensee failed to provide sufficient oversight to staff; failed to provide a home-like environment and failed to ensure the provision of appropriate care and services. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse",3,,Substantiated,Substantiated,Verbal/Mental abuse +NW152113B,522041,AFH,1/12/2015,"On or about January 12, 2015, the Department received a complaint which alleged the Licensee and her staff had limited Resident #1_x001A_s (RV) ability to communicate with others. During the course of the investigation, RV reported that Licensee and her staff would hide the phone or take the phone upstairs where RV could not access it. Witness #5 (W5) reported that he/she was given instructions to not allow RV access to the phone because Licensee did not want RV to be able to call senior services with any complaints he/she had about Licensee_x001A_s adult foster home. Additionally, W5 indicated that Reported Perpetrator #2 (RP2) listened in on residents_x001A_ personal phone calls. The investigation concluded that RV was denied access to the phone on a number of occasions. + + + +Licensee placed restrictions on RV_x001A_s ability to interact or communicate privately with other individuals. Licensee_x001A_s failure to provide RV with the ability to associate with any person of his/her choice is a violation of resident rights, is considered involuntary seclusion and constitutes abuse.",2,,Substantiated,Substantiated,Involuntary Seclusion +NW152346A,522041,AFH,7/21/2015,"On or about July 21, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV1), Resident #2 (RV2) and Resident #3 (RV3) from intimidation and emotional discomfort. + + + +During the course of the investigation, it was discovered that RV1 went outside to sit on the deck of the adult foster home (AFH). Reported Perpetrator #2 (RP2) yelled at RV1 to go sit somewhere else. RP2 then threw everything off the deck, except for a large table and the chair in which RV1 was seated. + + + +The Adult Protective Services Specialist also discovered that RP2 had yelled at RV2 about RV2_x001A_s bladder issues. RP2_x001A_s communication about RV2_x001A_s personal medical information was loud enough to be easily heard throughout the AFH, including by other residents. + + + +Witness #1 (W1) reported that RV3 asked to have some shrimp with his/her dinner one night. RP2 was angered by RV3_x001A_s request and RP2 slammed items. Witness #3 heard glass breaking during the altercation. + + + +The investigator assigned to this complaint allegation attempted to interview Reported Perpetrator #1 (Licensee) and RP2. Licensee forbade the APS investigator to ever contact her again, whether by telephone or in person. Licensee and RP2 did not participate in the interview process and did not provide input regarding the allegation. + + + +The investigation concluded that RP2 intimidated RV1 and intimidated and humiliated RV2 which resulted in loss of personal dignity. RP2_x001A_s conduct constitutes verbal and emotional abuse as defined in Oregon Administrative Rule 411-020-0002(1)(d). + + + +Licensee and her staff failed to cooperate with the Department during the complaint investigation process. Additionally, Licensee failed to provide sufficient oversight to staff; failed to provide a home-like environment and failed to ensure the provision of appropriate care and services. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Verbal/Mental abuse +NW152346B,522041,AFH,7/21/2015,"On or about July 21, 2015, the Department received a complaint which alleged the facility had failed to provide a safe medication administration system. During the course of the investigation, it was determined that Reported Perpetrator #2 (RP2) took anti-diuretic medication from Resident #3 (RV3) and gave it to Resident #1 (RV1) when RV1 experienced swelling in his/her legs. RV1 was dispensed RV3_x001A_s anti-diuretic medication for approximately five days. + + + +RP2 took medications belonging to and intended for the benefit of RV3 and gave them to RV1. RP2_x001A_s conduct constitutes financial exploitation as defined in Oregon Administrative Rule 411-020-0002(1)(e)(A) and (D). + + + +Licensee and her staff failed to cooperate with the Department during the complaint investigation process; failed to provide a safe medication administration system for RV1 and RV3; and failed to provide a safe environment. Licensee_x001A_s failure is a violation of resident rights, is considered neglect, and constitutes abuse.",3,,Substantiated,Substantiated,Financial abuse +MV121491,522046,AFH,11/1/2012,"On or about November 1, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from theft of medication. RV is scheduled to receive h/her narcotic pain medication 2x daily, once in the morning and once in the evening. It was determined eight of RV's narcotic pain medication pills were missing resulting in RV going 24 hours without h/her pain medication. The licensee failed to provide a medication system that prevents theft. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Financial abuse +MV146271,522046,AFH,3/2/2014,"On or about March 4, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate sexual contact. RV reported to Witness #2 (W2) that Reported Perpetrator #2 (RP2) had exposed him/her self to RV and expressed that he/she wanted to have sex with RV on multiple occasions. RV disclosed to W2 that RP2 continued to ""hound"" RV and that RP2 raped RV. RV stated to W2 ""I guess I gave in, I had sex"" and that ""it was the worst 5 minutes of my life."" RV was transported to the hospital for evaluation. The hospital registration record notes that a SANE exam was completed. The hospital registration record notes that RV sustained vaginal injury. A separate interview was conducted with RV. During that interview RV stated that RP2 had exposed him/her self to RV. RV stated that during the incident RP2 had pushed RV into the staff bedroom and picked RV up out of his/her wheelchair and onto the bed. RV verbally expressed to RP2 that ""I just don't think this is a good idea."" RV statetd that RP2 replied ""Oh, I think it is."" Law enforcement was notified. Facility failed to provide a safe environment. Licensee's failure is a violation of Oregon Administrative Rules. Update: Abuse apportioned to RP2, LOD sent 4/09/14.",4,,Not Substantiated,Substantiated,Sexual abuse +CO15173,522046,AFH,8/24/2015,"On or about August 12, 2015, the local licensing authority (""LLA"") conducted the annual re-licensure inspection at Licensee's Adult Foster Home (""AFH""). During the LLA's visit all smoking alarms were tested. It was observed the smoke alarm in Resident #3 bedroom was not installed. It was also discovered the smoke detector in caregiver room was not emitting sound. Upon a closer review it was determined that the battery had been removed from the smoke detector. During the same visit it was observed the smoke detector in the dining room and Resident #1 Room were not emitting sound when tested. Licensee's failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,500,,, +PT116547,522050,AFH,2/9/2011,"RV began to complain of pain on 2/7/11, but wouldn't let anyone look. When RV allowed W1 to check on 2/9/11, there was significant bruising and some swelling on RV's underarm and chest area. RV had been complaining of pain, but wasn't taken to the doctor until the afternoon of 2/10/11.",2,0,,, +NW120174,522061,AFH,3/16/2012,"On or about March 16, 2012, Complainant #1 visited Resident #1 in Licensee's adult foster home (AFH). Resident #1 was weak and had a number of skin ulcers on his/her body. Complainant #1 called for emergency medical services and Resident #1 was transported to the hospital. Emergency Department records indicate that Resident #1 was hypothermic with a body temperature of 90 degrees, clearly malnourished, and had multiple decubitus ulcers and contractures. The facility failed to provide appropriate care and services. The failure is a violation of Oregon Administrative Rules, is considered neglect, and constitutes abuse.",4,0,,,Neglect +MV129285,522064,AFH,2/14/2012,"It was reported that on or about February 14, 2012, Licensee failed to properly manage Resident #1's medications. On February 14, 2012, Resident #1 had come to Licensee's from the hospital. When Licensee tried to do required testing on Resident #1 he/she discovered the testing device was not operable. Licensee was not able to do the required testing and administered medication that should be adjusted based on the required testing results. Licensee did not do the required testing on Resident #1 for nearly 24 hours. Licensee's failures are a violation of Oregon Administrative Rules, is considered neglect and constitutes abuse, Wrongdoing on the part of the Licensee was substantiated.",0,0,,,Neglect +MV135091A,522064,AFH,9/25/2013,"It was reported that on or about September 25, 2013, Licensee failed to provide a safe medication system. Resident #1 went without medication because medication came up missing. Licensee's failures are a violation of Oregon administrative rules, is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Financial abuse +MV135091C,522064,AFH,9/25/2013,"It was reported that on or about September 25, 2013, Licensee failed to provide a clean environment. The AFH was visibly dirty and smelled of odors. Licensee's failures are a violation of Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV135091E,522064,AFH,9/25/2013,"It was reported that on or about September 25, 2013, Licensee failed to protect resident rights. Resident #1 was denied a meal if he she was late for dinner. Resident #2 went without food on ore than one occasion. Licensee's failures are a violation of Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MV135091B,522064,AFH,9/25/2013,"It was reported that on or about September 25, 2013, Licensee failed to provide a safe environment. Resident #1 and Resident #2 were left alone at times for an unknown period of time. Licensees failures are a violation of Oregon administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +DA145947,522077,AFH,1/29/2014,"On or about January 29, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). Witness #5 (W5) arrived to RP's and discovered there was not a qualified caregiver on duty. RP stated that RP had errands to run and RV was not at the adult foster when RP left. RP received a phone call that RV was back at the adult foster home without a qualified caregiver. RP then arrived back at the adult foster home. RV was left alone without a qualified caregiver. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",3,,,, +CO14057,522089,AFH,3/19/2014,,3,1150,,, +NB151717,522089,AFH,6/25/2015,"On or about June 25, 2015, Adult Protective Services (APS) received a complaint that RP2 is not providing care to RV. During the course of the investigation, the following was determined: Incident reports indicate RV had 5 falls within 3 months. RV's care plan indicates that RV has a history of falls and needs assistance with dressing/undressing when fatigued and having trouble with right side weakness. RV's state assessment indicates RV needs some assistance with dressing. RP2 states that he/she does not have time to assist RV in the morning and that RV can dress on his/her own. RP2 also limited RV's ability to view programs of choice on his/her personal computer. The facility uses 1/2 bed rails as a restraint so that RV can't fall out of bed. RV is unable to lower the bedrails on his/her own and the facility does not have the required documentation to use such restraints. RP2's actions are a violation of Oregon Administrative Rule and resident rights, are considered neglect, and constitute abuse. RP1's actions are a violation of Oregon Administrative Rule and unlawful use of restraints, which constitutes a type of abuse.",3,,Substantiated,Substantiated,Neglect +NB152753,522089,AFH,8/24/2015,"On or about August 24, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to protect RV from misappropriation of RV's resources for the gain of another. During the course of the investigation, APS determined that: RV was a resident of the facility where RP2 worked as an employee. RP2 and RV did not have a relationship prior to RV moving into the facility. RP2 attempted to obtain $20,000 from RV to open a foster home and did obtain $300 cash from RV. RP2 took money from a resident at the facility RP2 was employed at. RP2 was RV's caregiver and had undue influence over RV. RP2 made it known to RV that RP2 needed money to open a foster home and to get a business license. RV did give $300 cash to RP2 and planned to give $20,000 but decided not to. RP2's actions are also a misappropriation of RV's resources for personal gain, are considered financial exploitation, and constitute abuse. RP1's failure to protect RV from misappropriation of RV's resources for the gain of another are considered a rule violation.",3,,Not Substantiated,Substantiated,Financial abuse +NB151717A,522089,AFH,6/25/2015,"On or about June 25, 2015, Adult Protective Services (APS) received a complaint that a caregiver (RP2) did not provide care to a resident (RV). During the course of the investigation, APS substantiated that RV is a fall risk and has issues with balance, including right side weakness that leads to falls and therefore requires assistance with dressing. RV's facility care plan and RV's state assessment indicate that RV needs some assistance with dressing. RP2 states that he/she does not have time to assist RV in the morning and that RV can dress on his/her own. RP2's failure to assist RV with care needs is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +NB151717B,522089,AFH,6/25/2015,"On or about June 25, 2015, Adult Protective Services (APS) received a complaint that the facility failed to assess and intervene, resulting in multiple falls. During the course of the investigation, APS substantiated that a resident (RV) has a history of falls (five from March 4 through May 23, 2015). On October 25, 2015, RV had a fall resulting in a hip fracture and hospitalization. RV has mild cognitive impairment, as noted in the Foster Home care plan dated March 11, 2015. The State Assessment notes RV requires full assistance in awareness and judgment, assistance in memory, and that RV is not able to recall potential health consequences. Licensee (RP1) addressed RV's falls with reminders to use the walker and make good decisions and believed RV's failure to use walker or call light were behavioral. Facility staff were concerned RV's cognition was declining. Licensee's failure to assess and intervene, resulting in multiple falls, is a violation of resident rights, is considered neglect and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +NB151717C,522089,AFH,6/25/2015,"On or about June 25, 2015, Adult Protective Services received an allegation that a physical restraint was in place for a resident. During the course of the investigation, APS substantiated that on October 4, 2011, a physician's discharge order included a semi-electric hospital bed with side rails and home health including a teaching sheet to use bed railing to get in/out of bed in October 2011. The October 2011 care plan discussed 1/2 bed rails but the March 2015 care plan did not. OAR definitions note that half bed rails used to turn are not considered restraints if requested by resident. There is no indication the resident requested 1/2 bed rails. Licensee_x001A_s failure to use physical restraints properly is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,Substantiated,Substantiated,Restraints +CO15262,522089,AFH,12/23/2015,"Provider allowed a caregiver to work in the capacity of resident manager without meeting all the RM qualifications, without an application or fee, and without a bcu for the RM position.",3,850,,, +CO15263,522089,AFH,12/23/2015,"Provider has several violations of medication administration rules. Warning letter issued (note, this is the 2nd warning letter for this provider on medication issues, but not on the same home. Provider has multiple homes)",2,,,, +NB153195B,522089,AFH,10/18/2015,"On or about October 19, 2015, APS received a complaint that the facility failed to provide approriate care. During the course of the investigation, APS substantiated that RV has a medical condition that results in swallowing difficulties and choking hazards. RV will chew food and spit it back out or exhibit choking symptoms. RV had an order for ""Thick-it"" for liquids, but generally refused it. The facility staff treated the choking as a behavior, not a medical condition. Although RV requires substantial assistance with bathing and mobility, and required full assistance in cognition and elimination, facility staff expect RV to toilet independently and use mobility aids independently. The facility's failure to provide appropriate care constitutes neglect and is considered abuse.",2,,Substantiated,Substantiated,Neglect +NB153948A,522089,AFH,12/15/2015,"On or about December 15, 2015, APS received a complaint that the facility failed to follow doctor orders. Upon review of medication administration records, APS substantiated that RV1 did not receive medications as ordered. RV2, RV4, and RV5 did not receive medications as ordered. The facility was not accurately documenting administration of PRN medication and narcotics. The facility's failure to administer medications as ordered was a failure of residents rights, constitutes neglect, and is considered abuse.",2,1200,Substantiated,Substantiated,Neglect +NB153948B,522089,AFH,12/15/2015,"On or about December 15, 2015, APS received a complaint that the facility failed to provide appropriate care to RV1. During the course of the investigation, APS substantiated that RV1 is resistive to showering and changing clothes and must be cued and redirected to complete these activities. RV1 had only one shower between November 10, 2015 and December 17, 2015. RV1 has two sores on his/her buttocks area and also has redness and soreness on his/her inner thighs and genitalia. Staffing is not sufficient to meet the care needs of residents in a timely manner. The facility's failure to provide appropriate care is considered a violation of resident rights, constitutes neglect, and is considered abuse.",2,,Substantiated,Substantiated,Neglect +NB153948C,522089,AFH,12/15/2015,"On or about December 15, 2015, APS received a complaint that the facility failed to provide appropriate care to RV2. During the course of the investigation, APS substantiated that RV2 needs frequent changing of clothes, turning, requires compression stockings, and uses a colostomy bag. RV2 has been left in bed with wet hygiene garments, has not been changed at least three times daily as required by the care plan, and has not had his/her colostomy bag changed at least every four days as required by the care plan. RV2 has not been turned as required and the lack of care resulted in a large tissue discoloration on RV2's right hip from buttocks to mid-thigh. RV2's compression stockings have not been put on as required. RP2 no longer works at the facility. The facility's failure to provide appropriate care is a violation of resident rights, constitutes neglect, and is considered abuse.",3,,Substantiated,Substantiated,Neglect +NB153948D,522089,AFH,12/15/2015,"On or about December 15, 2015, APS received a complaint that the facility failed to provide a safe environment for RV1. During the course of the investigation, APS substantiated that caregiver RP2 showered and fell asleep on the sofa. RV1 wandered outside the facility without RP2 knowing he/she was gone. RP2 did not hear the alarm on the front door. The back door was not alarmed. Alarms in the resident rooms were not working. The facility was aware of RV1's elopement risk and were to have alarms on all doors. RP2 was picked up and taken to the hospital, which called the facility. The facility's failure to provide a safe environment was a violation of Oregon Adminsitrative Rule.",3,,Substantiated,, +ES134308,522140,AFH,8/29/2013,"On or about August 29, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim (RV). It was documented that RV has confusion and memory loss. RV did not have the ability to the call bell system that was in place. On one occasion RV wandared out of the facility and was later found outside of the adult foster home (AFH). Proper precautions were not taken in order to prevent RV from exit seeking. The licensee failed to provide a safe environment for RV.",2,,,, +CO14195,522161,AFH,9/30/2014,FOD sent to provider and a copy sent to LLA 12/08/14,3,250,,, +MS152766,522161,AFH,8/4/2015,"On or about September 9, 2015, APS received a complaint that the facility failed to protect reported victims (RVs) from wrongful taking of resources. During the course of the investigation, APS substantiated the following: RV1 had a large sum of cash sitting in an envelope on RV1's night stand, out of which $20.00 went missing and was never found. RV2 reported missing money after RV1 reported missing money; RV2 is missing $20.00 from two separate incidents and $6.00 in quarters. RP was aware of theft within the facility prior to RV's reporting missing money. RP had fired a prior employee for theft. RP did not provide secure storage space for residents to store money and valuables. This is a violation of Oregon Administrative Rules. It is not known who took RV1's and RV2's money.",2,,Not Substantiated,Substantiated,Financial abuse +RD129322C,522163,AFH,2/14/2012,"It was reported that on or about February 14, 2012, Licensee failed to protect Resident #1 (RV1) from inappropriate verbal comments and emotional distress. Licensee would tell RV1 not to contact his/her family and complain or his/her family would not want to visit RV1. Licensee would listen in on RV1's phone conversations, would take the phone from RV1 and interject his/her statements into the conversation, then return the phone back to RV1. Licensee videotaped RV1's behavior while he/she was in the living room one day to prove to RV1's family he/she was not unhappy at the facility. On the day RV1 was being videotaped Licensee did joke with RV1 about making funny faces although RV1 did not find it funny. Licensee's actions are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS116307A,522166,AFH,2/9/2011,"On or about January 26, 2011, Resident #1 (RV1) fell at approximately 4am. RV1's family was not notified until approximately 6:30am. Between 7am and 7:30am, a caregiver found RV1's leg swollen. Caregiver notified W5 to come to the facility and assess RV1's leg. W5 called 911 after 8am. RV1 had sustained a broken hip.",2,0,,, +MS116307B,522166,AFH,2/9/2011,"On or about February 9, 2011, a report was received alleging that Licensee had failed to provide appropriate care and services to Resident #1 (RV1) and Resident #2 (RV2). The investigation concluded that the Licensee had failed to put interventions in place to address RV1's wandering and fall risks and RV2 had experienced multiple skin breakdowns while residing at the facility. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS116417,522166,AFH,12/24/2010,"RV1 moved into the AFH in October of 2010 and according to AFH MARS had 14 prescribed medications. RV1 refused medication sporadically during his/her stay at the facility, and had not taken any medication the week prior to leaving. According to a progress note dated 11/10/11, RV1 refused medications due to believing the medication did not belong to him/her, and that he/she suspected someone was trying to poison them. RV1's care plan did not show that any interventions were initiated to address RV's refusal medications. The facility failed to adequately care plan for RV1's behaviors in relation to medication refusal.",2,0,Not Substantiated,Substantiated, +MS120891,522166,AFH,8/13/2012,Indiv apportionment,3,0,Not Substantiated,Substantiated,Financial abuse +MS132749A,522166,AFH,3/26/2013,"Physician_x001A_s orders dated March 15 and March 18, 2013 indicated that Resident #1 was to be administered one 5mg tablet of Medication #1 each evening at bedtime. A review of Resident #1_x001A_s Medication Administration Record (MAR) for March 2013 indicates Medication #1 was first dispensed on March 19, 2013. Medication #1 is listed three times on the resident_x001A_s MAR, once by its generic name and twice by its brand name. On March 19, 2013, the line that lists Medication #1 by its generic name, the MAR was initialed to indicate Resident #1 was administered one 5mg dose. On a separate line on the MAR that lists Medication #1 under its brand name, the MAR was initialed to indicate a second 5mg dose was administered that same evening. On March 20, 2013, the facility received a fax from a medical assistant who is not an authorized prescribing practitioner. The fax had instructions to double the dosage of Medication #1. A review of Resident #1_x001A_s MAR for the evening of March 20, 2013 shows that Resident #1 was dispensed a total of 25mgs of Medication #1: one 5mg dose as documented under the generic medication name, two 5mg tablets under the brand name and another two 5mg tablets as indicated on a separate line of the MAR which also lists the medication by its brand name. + + + +At admission to the adult foster home (AFH) on March 14, 2013, Resident #1 had a prescription for Medication #2. Resident #1 was to be dispensed one 25mg tablet twice per day. Resident #1_x001A_s MAR indicates he/she was administered one 25 mg tablet beginning the evening of March 14, 2013 through the morning of March 20, 2013. Resident #1_x001A_s MAR does not indicate that an evening dose was dispensed on March 20, 2013. On March 20, 2013, the facility received a fax from Resident #1_x001A_s medical clinic that indicated the dosage for Medication #2 should be increased to 50mg given twice daily for the next 48 hours. The fax was signed by a CMA, not an authorized prescribing practitioner. On March 21, 2013, Resident #1 was dispensed one 50mg tablet without a physician_x001A_s order. + + + +Resident #1 had prescription dated March 15, 2013 for one 1.0mg tablet of Medication #3 to be given twice daily as needed for agitation. A second prescription for Medication #3 dated March 18, 2013 indicated that resident can take one 0.5mg tablet twice each day as needed. The written parameter dated March 19, 2013 stated that the amount dispensed was not to exceed two 0.5mg tablets per day. Resident #1_x001A_s medication records for March 2013 were reviewed. The MAR was initialed to indicate that a total of four 0.5mg tablets of Medication #3 were dispensed on March 19, 2013. On March 20, 2013, the facility received a fax from a medical assistant who is not an authorized prescribing practitioner with instructions to dispense two 0.5mg tablets twice a day as needed for the next 48 hours. The dates and times initialed indicate that Resident #1 received a total of four 0.5mg tablets the morning of March 20, 2013 and two 0.5mg tablets the morning of March 21, 2013. The reason the PRN medication was given each time and the outcome to the resident was not recorded on the reverse side of each MAR. + + + +On March 21, 2013, Resident #1 was transported to the hospital. A document from the medical facility where Resident #1 was treated refer to Resident #1 having an altered mental status and was _x001A_exceedingly somnolent_x001A_ due to a medication reaction. + + + +Licensee failed to administer medications as ordered, failed to obtain written orders and failed to properly document the administration of PRN medications. These failures are in violation of resident rights, are considered neglect and constitute abuse.",3,400,,,Neglect +MS132749B,522166,AFH,3/26/2013,"Resident #1 was admitted to licensee_x001A_s adult foster home (AFH) on March 14, 2013. + + + +On March 14, 2013, Department staff discussed Resident #1_x001A_s history of wandering and physical outbursts. + + + +A screening assessment dated March 14, 2013, includes that Resident #1 has behavioral issues such as _x001A_getting upset and will yell and scream. Can redirect._x001A_ This document prepared by the licensee also states that _x001A_We [the facility] will make sure RV gets redirected if RV gets upset._x001A_ + + + +Resident #1_x001A_s care plan dated March 13, 2013 does not mention his/her history of physical outbursts or list any interventions. The care plan does include under _x001A_Night Needs_x001A_ that Resident #1, _x001A_Tries to go out the door all the time_x001A_ but does not provide what assistance or supervision the resident requires. + + + +Resident #1_x001A_s progress notes between March 16, 2013 and March 20, 2013 indicate that Resident #1 was becoming increasingly agitated and aggressive at night. The facility contacted Resident #1_x001A_s medical professional and requested that the dosages for three of Resident #1_x001A_s medications be increased in order to reduce behaviors. + + + +During the course of the investigation, the licensee stated that Resident #1 was fairly calm when the licensee evaluated Resident #1 at his/her former living environment so _x001A_I [the licensee] decided to try admitting RV and seeing how it went. The licensee further acknowledged that he/she _x001A_did not get any documents from the facility RV was at._x001A_ + + + +Licensee failed to conduct a thorough screening and failed to document a complete care plan. The failures are violations of Oregon Administrative Rule.",2,,,, +CO14081,522166,AFH,4/2/2014,Imposition of civil penalty: No RM/Licensee not living in home (repetitive) and Licensee failed to notify LLA re: change in primary caregiver (also repetitive). FOP sent,3,550,,, +MF147986,522167,AFH,8/1/2014,"On or about August 1, 2014, APS received an allegation that the facility failed to protect residents from the loss of medications. During the course of the investigation, APS determined that the facility was providing care for the resident and handling the resident's medication. The facility paid for, kept, and used the resident's narcotic pain medication. The resident did not receive his/her narcotic pain medication. The facility failed to protect the resident from the loss of medications. This failure is a violation of resident rights and constitutes financial abuse.",2,,,,Financial abuse +KF116391,522170,AFH,2/19/2011,"It was reported that on or about February 22, 2011, that the Licensee failed to protect Resident #1 (RV1) from humiliation. Interviews concluded that the Licencee made inappropriate verbal comments about RV1 to Witness #4 (W4) while in front of two other resident. Wrongdoing on the part of the Licencee was substantiated.",2,0,,, +KF117199,522170,AFH,6/13/2011,"On May 16, 2011, Reported Perpetrator (RP) requested Reported Victim's (RV) neurologist to discontinue his/her Parkinson's medication due to a decline in health. RV's family was upset that RP made the decision to discontinue RV's Parkinson medication and requested that the medication be reinstated. On approximately June 1, 2011 RP removed RV's egg crate mattress due to soiling but the mattress pad was not replaced until RV started hospice services on June 11, 2011. On June 7, 2011 RP observed multiple bed sores on RV in various locations. On June 11 and June 14, 2011 a full body audit was conducted on RV. RV was documented to have 10 different wounds in various stages of skin breakdown. RP failed to intervene timely when RV's condition changed.",2,0,,,Neglect +SV118745,522176,AFH,12/10/2011,"It was reported that on or about December 10, 2011, Licensee failed to protect Resident #1 (RV1) from inappropriate verbal communications. RV1 felt hurt by Reported Perpetrators #2's (RP2) communications with RV1. Licensee's failures are a violation of Oregon Administrative Rule. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO11040,522182,AFH,1/11/2011,,2,250,,, +RB118067,522246,AFH,8/22/2011,"On or about August 23, 2011, it was reported that Reported Perpetrator (RP) failed to follow physician orders for Reported Victim (RV). It was determined that RV was ordered physical therapy by RV's physician. RV did not receive physical therapy as ordered. The licensee failed to provide medical treatment as ordered.",0,0,,, +RS152296,522246,AFH,1/5/2015,"Resident Victim #1 (RV1) opened a bank account and listed Licensee as the Rep- payee on the account. Licensee was to give RV1 $153.00 per month. Licensee stated she would give RV1 $150.00 and would withhold the remaining $3.00 for incidental expenses when they were in town. Licensee did not keep receipts for any of the handling of RV1's funds. Licensee stated used RV1's account to purchase groceries for the AFH. + + + +On 3/4/15 Licensee used RV1;s account to purchase eating utensils for the AFH. On 3/6/15 Licensee used the RV1's account to purchase dog food for Licensee's dog. On 04/03/15 Licensee had a personal doctor appointment and used the RV1's account to pay her co-pay for the visit. On 4/27/15 Licensee used the RV1's account to purchase cleaning supplies for the AFH. On 4/28/15 Licensee used the RV1's account to purchase furniture for the AFH. Licensee stated she did comingle funds of RV1's and stated she knows it was not acceptable. A total of $2,333.55 in purchases charged against RV1's account was used for the purpose of running Licensee's AFH. Licensee's actions are considered financial exploitation and constitute abuse.",3,400,Substantiated,Substantiated,Financial abuse +AL129039B,522294,AFH,7/1/2011,"It was reported that on or about July 1, 2011, Licensee used threatening language while Resident #1 (RV1) was attempting to exercise resident rights. When RV1 attempted to exercise his/her right not to return to Licensee's Adult Foster Home (AFH) after an outing with Witness #2 (W2) and Witness #3 (W3), Licensee phoned W2 numerous times and engaged in an argument with W2 and W3. During the verbal exchange between W2, W3 and Licensee, Licensee used threatening language that was directed at RV1 that was within hearing range of RV1. Licensee's failures are a violation of Oregon Administrative Rule and constitute verbal/mental abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Verbal/Mental abuse +KF150986,522298,AFH,4/20/2015,,2,,Substantiated,Substantiated,Neglect +MV149524,522303,AFH,12/9/2014,"It was reported that on or about December 9, 2014, Licensee failed to maintain an adequate medication system. Licensee failed to follow physician orders for Resident #1's (RV1) prescribed medications and failed to accurately document RV1's physician's orders and administered medications on RV1's medication administration record. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO16007,522303,AFH,12/9/2015,for failure to have a qualified caregiver(Licensee + 2 caregivers ) present and available in the AFH on duty 24 hours per day as required by OARS.,3,850,,, +CO12055,522307,AFH,5/17/2012,Home closed on 9/6/2012,3,0,,, +MS117260,522312,AFH,6/17/2011,"On or about June 20, 2011 it was reported that RV1 and RV2 were upset because they thought the Licensee and his/her spouse were arguing. RV1 and RV2 did not understand the language RP1 was speaking.",2,0,,, +MS150719A,522312,AFH,3/27/2015,"On or about March 27, 2015, APS received a complaint that the facility failed to provide appropriate care. During the course of the investigation, APS substantiated the following: RP1 is inconsistent with making RV's doctor appointments and transportation to appointments. RP1's failure to meet RV's care needs and failure to provide transportation are a violation of Oregon Administrative Rules.",2,,,,Neglect +MS150719B,522312,AFH,3/27/2015,"On or about March 27, 2015, APS received a complaint that RP2 calls RV disparaging names. During the course of the investigation, APS substantiated that RP1 and RP2 both have called RV either large and/or fat and this hurts RV's feelings. RP1 and RP2 have failed to provide a safe environment and the failure is a violation of resident rights, is considered verbal/mental abuse, and constitutes abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +MS150719C,522312,AFH,3/27/2015,"On or about March 27, 2015, APS received a complaint that RP1 and RP2 handle RV roughly. During the course of the investigation, APS substantiated the following: RV has cognition. RP1 and RP2 get angry with RV and handle RV roughly when they are changing RV, causing RV injury. The facility failed to protect RV from rough treatment by RP1 and RP2, which failure is considered physical abuse.",2,,Substantiated,Substantiated,Physical Abuse +GP118677,522343,AFH,12/13/2011,"It was reported that on or about December 13, 2011, Licensee failed to provide An adequate, clean and safe environment for Resident #1 (RV1). RV1's room was cold prior to being provided with a free standing heater. RV1's room was cluttered, dirty and not home-like. RV1's clothing and hair were unclean and unkempt. A commode in RV1's room was smeared with feces and the home where RV1 lived was not clean, odor-free or free of clutter. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +HB116488,522355,AFH,3/8/2011,"RV1's physicians order for Medication B was to be given every 6 hours for pain starting on 03/05/11. According to facility MAR and a handwritten note dated 3/6, RV1 was given Medication B more frequently than was ordered on 03/06/11 and 03/07/11. The facility failed to follow a physicians written order for medication.",1,0,,Substantiated,Neglect +HB132870A,522355,AFH,4/2/2013,"On or about April 2, 2013 at approximately 7:30am, Witness #1 notified Reported Perpetrator #2 that Resident #1 needed assistance with elimination. Reported Perpetrator #2 did not address Resident #1's needs until approximately 9:30am during which time Resident #1 was left sitting in a soiled garment. Facility failed to provide appropriate care and services. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RB116976A,522378,AFH,5/8/2011,"On or about May 12, 2011 it was reported that RP1 was leaving for the morning and had dispensed the resident's medications in a cup with their names on each cup for RP2. Residents were sitting at the table for breakfast and RP2 sat the cups in front of each resident. RV took his/her medication right away. It wasn't until the other resident went to take his/her medications that it was discovered they were wrong. RV had received the other resident's medications. The other resident did not receive RV's medication.",2,0,,, +RB120572,522378,AFH,7/3/2012,"On or about July 3, 2012, it was reported that Licensee failed to protect Resident #1 from, threats of punishment, deprivation, humiliation and harassment. On the morning of July 3, 2012, Resident #1 had a bowel movement from his/her room throughout the entire house then returned to bed with feces all over him/her and the bedding. Licensee woke Resident #1 up, when Licensee saw the mess, Licensee said ""fuck"", called Resident #1 stupid and said get down and scrub it. Licensee told Resident #1 that he she was giving Resident #1 a 30 day notice. Licensee then told Resident #1 not to worry about the 30 day notice and he/she would review things at the end of 30 days then review every 30 days thereafter. Licensee's failures are a violation of Oregon Administrative Rules, and constitute verbal/mental abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Verbal/Mental abuse +CO14002,522378,AFH,11/13/2013,"On November 13, 2013, the licensor made an unannounced visit to the licensee_x001A_s adult foster home (AFH). During the visit the licensor discovered smoke detectors had not been installed in bedroom #1, bedroom #2, bedroom #3 and the upstairs living area as required. The licensee failed to install all required smoke detectors. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,1000,,, +CO14241,522378,AFH,12/10/2014,"On or about December 9, 2014, the local licensing authority (LLA) received information from the Background Check Unit (BCU) that the licensee_x001A_s background check had been denied to hold the position of adult foster home (AFH) licensee. The licensee was not entitled to appeal the determination from BCU. + + + +Licensee failed to maintain an approved background check. Licensee failed to meet the qualifications to reside in and operate an AFH. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,,,, +SV117364A,522384,AFH,7/1/2011,"On or about July 1, 2011 it was reported that RP3 was caring for RV's without being approved to do so. RP3 has been found to have a disqualifying criminal history. RP1 allowed RP3 to come to the AFH.",1,0,,, +SV117712,522384,AFH,8/9/2011,"On or about August 15, 2011, it was reported that the Licensee failed to protect Resident #1 (RV1) from threats and humiliation. Reported oerpetrator #2 (RP2) raised his/her voice at RV1 causing emotional discomfort. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Verbal/Mental abuse +CO13005,522398,AFH,12/5/2012,"On December 5, 2012, the licensor made a visit to the licensee_x001A_s Adult Foster Home (AFH). During the visit the licensor discovered that the required smoke alarm in Resident #2_x001A_s bedroom had been removed. + + + +The licensor also found that the interconnected smoke alarm in Resident #3_x001A_s bedroom was not functional. The licensor tested the interconnected smoke alarm when the power was shut off and the battery back up was also not functional. The licensee failed to provide a safe environment for Resident #2 and Resident #3. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,300,,, +CO13132,522398,AFH,10/22/2013,"On or about February 2012, RV was admitted to the licensee_x001A_s adult foster home (AFH). RV relies on h/h wheelchair for mobility. RV is able to operate the wheelchair by his/her self and can transfer out of his/her wheelchair with the use of handrails. RV uses the bathroom frequently at night. On multiple occasions Reported Perpetrator (RP) removed RV_x001A_s wheelchair from RV_x001A_s bedroom at night which prevented RV from using the bathroom. RP acknowledged taking away RV_x001A_s wheelchair because RV was getting up between 10-20 times at night. RP stated that that he was trying to come up with a system because RV _x001A_needs to stay in his/her bed or wear depends._x001A_ RP also told RV that there is no reason to go to the bathroom or roam the house in the middle of the night. Witness #2 (W2) observed RP take RV_x001A_s wheelchair out of RV_x001A_s bedroom at least one time. RV was told by RP that RV was not allowed to leave his/her room until a caregiver was downstairs to help assist him/her. The licensee failed to protect RV from involuntary seclusion. The licensee_x001A_s failure is a violation of resident rights, is considered involuntary seclusion, and constitutes abuse. UPDATE: CP Paid 12/5/13",3,400,,,Involuntary Seclusion +AL117558B,522403,AFH,5/23/2011,"On May 23, 2011, RP2 and W4 were showering RV when RV fell into the shower and bumped his/her head. RP2 became frustrated with RV and in RP2's frustration, proceeded to direct comments to RV that a reasonable person would interpret as derogatory in nature. The Licensee failed to protect RV from verbal language that was inappropriate.",2,0,,,Verbal/Mental abuse +AL153334,522403,AFH,9/27/2015,"On or about 09/25/15 facility staff found RV sitting on the floor of his/her room in the middle of the night. Facility staff looked RV over and found no bruising or other visible injury, but thought RV had a hip injury because RV was crying out, and subsequently was lying in bed screaming. RV had a history of crying out during her ten-month stay at the facility. Facility staff reported that RV had been independent with ambulation until around the 09/25/2105 fall. Over the next two week period facility staff stated RV had a change of condition, with more screaming, not wanting to get out of bed, hitting and scratching staff, and yelling when staff tried to get RV out of bed. Facility staff stated RV's family was not notified of the change since the 9/25/2105 fall because it seemed a simple thing like RV ""landing on his/her butt."" Facility Incident Reports relating to falls, stated that on 09/19/15 RV went to sit on a chair that was not there and fell to the ground, landing on his/her bottom. A second Incident Report dated 9/26/2015 states RV was found on the floor of his/her room, screaming and hitting staff when given assistence. RV said he/she was okay but was upset, was given a PRN medication, and put back in bed. RV denied pain. Between 09/28 and 10/04/2015 facility records note that RV was refusing food and drink and other care. RV also refused medications, was unable to stay awake and was hard to wake up. On 10/02/2105 a Facility Incident Report indicates when staff checked on RV at about 4:30 a.m. on 10/01/2015, RV was on the floor with his/her head touching the closet door. Both of RV's legs were bent back towards his/her bottom on the right side. Staff asked if RV's head hurt and RV said he/she felt no pain. On 10/04/2105 RV's family visited and became very concerned about RV's condition, as RV was screaming and crying and very combative. It was difficult to rotate RV to his/her left side. On 10/07/2015 at the request of RV's family, RV was transported to a hospital, and diagnosed with with a left hip fracture and two subdural hematomas. Law enforcement was notified.",4,1000,Substantiated,Substantiated,Neglect +ES129719,522407,AFH,4/9/2012,"On or about April 9, 2012, it was alleged that Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) failed to prevent theft of Reported Victim's (RV) medication. It was determined that 96 of RV's narcotic medication pills went missing between 4/4/12 and 4/9/12. Approximately 116ml of RV's liquid pain medication was missing from the medication bottle between 4/3/12 and 4/10/12. The licensee failed to prevent theft of RV's medication. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AL132955,522429,AFH,12/19/2012,"It was reported that on or about December 19, 2012, Licensee failed to assist Resident #1 with toileting. Residents family did request the facility to assist Resident #1 with toileting. Resident #1's CAPS assessment indicated Resident #1 as needing toileting assistance. Licensee failed to provide the appropriate assistance to Resident #1 as required, resulting in Resident #1 frequently urinated on carpet, was incontinent of bowel in his/her bedroom, and at times plugged the toilet by flushing excess toilet paper. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS133206,522439,AFH,5/10/2013,"It was reported that on or about May 10, 2013, Licensee failed to protect Resident #1 from physical injury. Reported Perpetrator #2 (RP2) assisted Resident #1 to the table. RP2 failed to remind Resident #1 to lift his/her arms as they approached the table. Resident #1's arm went and under the table top and as a result Resident #1 sustained skin tears on his/her arms. Licensee failures are a violation or Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +RD149409,522445,AFH,11/26/2014,"On November 28, 2014, the Department received a complaint which alleged that on the evening of November 26, 2014, two residents of Licensee_x001A_s adult foster home (AFH) were left alone. + + + +The investigation determined that on the evening of November 26, 2014, Reported Perpetrator #2 (RP2) was the only caregiver on duty at Licensee_x001A_s AFH. RP2 acknowledged that after he/she assisted Resident #1 (RV1) and Resident #2 (RV2) to bed that evening, RP2 took two different anti-anxiety medications by mouth and drank hard liquor. RP2 later left the AFH and drove to a convenience store. Police arrived at the convenience store in response to a report of a suspected drunk driver. RP2 was arrested. Police were dispatched to the AFH where they found RV1 and RV2 alone and in bed but awake. Another caregiver was contacted and arrived at the AFH within a few minutes. + + + +The investigation concluded that RP2 failed to fulfill his/her responsibility to provide care and services for RV1 and RV2. RP2_x001A_s actions are considered neglect and constitute abuse as defined in OAR 411-020-0002(1)(b)(A)&(B). Responsibility for the abuse was apportioned to RP2. + + + +It was further determined that the facility failed to have a qualified caregiver present and available in the adult foster home twenty-four hours per day, seven days per week. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",3,250,Not Substantiated,Substantiated,Neglect +GP120185,522492,AFH,7/11/2011,"On or about July 11, 2011, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from financial exploitation. It was determined that RV felt pushed into selling h/her vehicle to RP. RP bought RV's vehicle substantially below market value at $4184.00. As a result, RP has entered into a written agreement with RV that RP will pay no less then $100 a month until RP has paid RV an additional $4878.80. RP failed to protect RV from loss of dignity. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO15026,522492,AFH,2/4/2015,,3,250,,, +CO16013,522492,AFH,1/19/2016,"Licensee did not narrate progress notes for R1 since January 27, 2015 and for R2 since May 23, 2015. Request for CP sanction and agravated based on a related violation written January 24, 2013. $200.00 CP granted.",3,200,,, +CO15242,522494,AFH,12/3/2015,Expired 301 (Licensee) Clearance Background,3,250,,, +MV120212,522498,AFH,6/2/2012,"On or about June 2, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV was admitted to the Adult Foster Home (AFH) and after 6 hours RV wandered outside and was found by law enforcement at 3:30am and taken to the hospital. RP was informed prior to RV being admitted that RV was a wander risk and frequently wakes up disoriented. One door in the AFH did not have an alarm in place. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +NB132143A,522543,AFH,1/8/2013,"On or about January 8, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to administer ordered medication to Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3). It was determined that Reported Perpetrator #2 (RP2) did not administer RV1's, RV2's, and RV3's medications from 1/8/13-1/10/13. RP2 believed that the RV's were out of medication for that time period. RP1 stated that all medications were in the adult foster home (AFH). RP2 acknowledges not administering RV1's, RV2's, and RV3's medications for that time period. The licensee failed to administer ordered medication to RV1, RV2, and RV3. The failure is violation of Oregon Administrative Rules.",2,0,,, +NB133807C,522543,AFH,7/3/2013,"On or about July 16, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1). RV1's care plan states that RV1 has a difficult time using the commode and did better on the toilet. On multiple occasions RV1 was restricted access to the resident restroom to use the toilet. Witness #4 (W4) acknowledged blocking entrance to the restroom. The licensee failed failed to protect RV1 from involuntary seclusion. The failure is violation of resident rights and constitutes abuse.",2,,,,Involuntary Seclusion +NB153854,522543,AFH,12/8/2015,"Reported Victim #1 (RV1), Reported Victim #2 (RV2), and Reported Victim #3 (RV3) were residents of Licensee's AFH. During an investigation initiated on December 8, 2015, it was discovered that licensee was using a chest strap (physical restraint) with the buckle placed on the back of RV1, to restrain RV1 to his/her wheelchair. It was also discovered that Licensee was using bedrails (physical restraints) for RV1, RV2, and RV3 without having complied with the requirements to use physical restraints. Additionally, it was discovered that Licensee had placed video surveillance cameras in RV1_x001A_s and RV2_x001A_s bedroom without having complied with the necessary requirements to use video surveillance.",2,1150,Substantiated,Substantiated,Physical Abuse +MM117208,522554,AFH,6/3/2011,"On or about June 3, 2011, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4), and Reported Victim #5 (RV5) from unreasonable restrictions. It was determined that RV1, RV2, RV3, RV4 and RV5 were restricted from socializing with one another in the Adult Foster Home (AFH). The licensee failed to protect RV1, RV2, RV3, RV4 and RV5 from involuntary seclusion. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Involuntary Seclusion +DA129034,522554,AFH,1/10/2012,"On or about January 10, 2012, it was alleged that Reported Perpetrator #2 (RP2) failed to administer medication as prescribed. It was determined medication Levothyroxine was to be given to RV1 two hours before or after the intake of a multi-vitamin and mineral supplements. RP2 administered Levothyroxine at the same time RP2 administered the multi-vitamin and mineral supplements. RP2 failed to administer a medication to RV1 as ordered. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM129754,522556,AFH,3/2/2012,"On or about March 2, 2012, Resident #1 (RV) arrived to the licensee_x001A_s Adult Foster Home (AFH) from an outing. RV requested to have h/h night time medications at approximately 7:30pm. Reported Perpetrator #2 (RP2) administered RV_x001A_s medications at 7:30pm. At approximately 8:00pm, RP2 administered RV another cup of medications. After RV consumed the medications, RP2 realized that RV was administered another resident_x001A_s medications. RP2 contacted Reported Perpetrator #1 (RP1). It was decided that RP2 would _x001A_keep an eye_x001A_ on RV. RV was checked on four times during the night. RV reported to be light headed and dizzy. The following morning RV was discovered slumped over in h/h chair, moaning and slurring h/h words. RP2 contacted 911 and RV was transported to the hospital for treatment. RV was kept in the hospital for three days in the intensive care unit due to an overdose of medication. The licensee failed to provide a safe medication administration system. The licensee_x001A_s failure is violation of Oregon Administrative Rule and constitutes abuse. NOTE: Sent to AR to begin aging process",3,400,,,Neglect +MM133664,522556,AFH,6/28/2013,"On or about June 28, 2013, it was alleged that Reported Perpetrator (RP) failed to administer Reported Victim's (RV) medication as ordered. RV was ordered to receive 10mg of pain medication three times daily. On 6/13/13 and 6/14/13 RV was administered 20mg of pain medication double the dose of what was prescribed. After RV's pain medication was discontinued RP acknowledged not properly disposing the pain medication. The licensee failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM121494,522556,AFH,10/20/2012,"On or about October 20, 2012, it was alleged that Reported Perpetrator (RP) failed to provide medical treatment as ordered for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). Witness #1 (W1) was informed that Reported Perpetrator #2 (RP2) had not administered RV1's and RV2's blood sugar checks as ordered. W1 checked the meter and RV1's Medication Administration Record (MAR). W1 noticed that numbers were missing on the meter. W1 also noticed the numbers on the meter did not match the numbers on the MAR which demonstrated that RP2 did not accurately or consistently check RV1's and RV2's bood sugar. The licensee failed to provide medical treatment as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO15228,522582,AFH,11/10/2015,"for failure to have current criminal background checks for: Licensee, caregivers, volunteers and occupants.",3,850,,, +CO14159,522629,AFH,7/29/2014,"Licensee failed to have a qualified caregiver present and available in the AFH, twenty-four hours per day, seven days per week. FOP sent 12/08/14",3,250,,, +CO11100,522634,AFH,7/1/2011,,3,250,,, +MS135071,522634,AFH,11/14/2013,"It was reported that on or about November 14, 2013, Licensee failed to provide a safe medication administration system. Reported Perpetrator #2 (RP2) failed to administer two of Resident #1's medications as ordered. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +ES132543,522647,AFH,3/1/2013,"On or about March 1, 3013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. RP1 and RV were arguing back and forth. During the argument, RP1 told RV to ""shut up"" and told RV to go to his/her ""fucking room"". RV felt ""bad"" after RP1 made the comments. The licensee failed to protect RV from loss of dignity. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Verbal/Mental abuse +AS117735,522650,AFH,7/13/2011,"On or about July 13, 2011, it was reported that the Licensee failed to protect RV from financial exploitation. On August 21, 2011, RP2 was arrested on multiple counts as a result of unlawfully withdrawing money from RV_x001A_s bank account. Additionally RP2 admitted to the theft and use of RV_x001A_s debit card.",3,0,Not Substantiated,Substantiated,Financial abuse +AS129330,522650,AFH,2/21/2012,"On or about February 21,2012, it was alleged that Reported Perpetrator (RP) failed to obtain and administer medications appropriately. It was determined through interviews and observations that RV did not receive an as needed pain medication from 1/10/12-1/27/12. The last filling of the prescription was on 2/5/12. The licensee failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO12031,522659,AFH,4/4/2012,Multiple medication errors putting residents at risk of serious harm .,2,0,,, +CO15236,522659,AFH,11/18/2015,"Condition issued, will not pursue CP",4,,,, +HB153282A,522659,AFH,10/24/2015,"It was reported that on or about October 24, 2015, Licensee abandoned her AFH. Licensee left the facility on 10/24/15 and did not return until 1:00 PM on 10/25/15. Licensee left Witness #2 (unknowingly) with the resident's of the AFH and did not tell witness #2 she was going to do so. As a result of leaving witness #2 alone with the resident's, the resident's went without proper care and services and did not receive their ordered medications. Licensee's failures are a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +MM129926,522682,AFH,4/13/2012,,2,0,Not Substantiated,Substantiated,Physical Abuse +CO14004,522685,AFH,12/3/2013,"A licensing visit conducted by the local licensing authority on December 3, 2013, discovered Licensee admitted Resident #1 into the home on or about June 21, 2012. Resident #1 was full assist in five activities of daily living (ADL)at the time he/she was admitted to the home. Licensee is approved to operate a Class 2 Adult Foster Home (AFH) and can provide care to individuals requiring full assistance in no more than three ADLs. Additionally, Licensee was unable to demonstrate timely evacuation of Resident #1 from the AFH. Licensee's failure is a violation of Oregon Administrative Rules. UPDATE: FOD complete 6/8/14 and an e-mail was sent to AR to start the AGING PROCESS.",3,400,,, +RD121907,522694,AFH,11/9/2012,"On or about November 9, 2012, Licensee was advised to contact Resident #1_x001A_s (RV1) physician due to RV1 exhibiting symptoms of infection. On or about November 13, 2012, it was discovered that RV1_x001A_s physician had not been notified and RV1 was experiencing discomfort. Licensee was directed to ensure RV1_x001A_s physician was contacted that day. Licensee contacted RV1_x001A_s physician on November 13, 2012. RV1_x001A_s physician placed RV1 on antibiotics to treat RV1_x001A_s infection. + + + +Licensee indicated that he/she had forgotten to contact RV1_x001A_s physician. RV1 suffered several days of discomfort due to an infection that was not treated in a timely manner. Licensee failed to intervene when RV1 experienced a change in condition. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,400,,,Neglect +BO151010B,522694,AFH,3/16/2015,"On or about March 16, 2015, APS received a complaint that the facility failed to administer a medical order. During the course of the investigation, APS determined that medications were prescribed to RV on March 2, 2015. Although medications were listed on RV's medication administration record, they were not given as ordered. The facility failed to administer needed medications, which is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +AL118811,522710,AFH,9/12/2011,"On August 23, 2011, Licensee received 30 tablets of narcotic medication for Resident #1. On September 12, 2011, it was discovered there were only 2 tablets remaining in the narcotic medication bottle and 22 tablets were missing. + + + +Licensee acknowledged he does not keep narcotic counts and that approximately 20 caregivers had been working in the home since the time he received the narcotics. Additionally, licensee admitted he only locks narcotic medications and that all non-narcotic medications are unlocked. + + + +Licensee failed to protect the resident from theft of medications. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,400,,,Financial abuse +MV121810,522788,AFH,11/9/2012,"On or about November 9, 2012, it was alleged that the Reported Perpetrator (RP) failed to protect the Reported Victim (RV) from verbal abuse. RP made inappropriate and derogatory remarks toward RV resulting in RV being fearful of RP. It was determined that the licensee failed to protect RV from verbal abuse. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Verbal/Mental abuse +MV148338,522788,AFH,8/16/2014,"RV moved into a facility with personal items (dvd and vhs movies, and craft supplies). These personal items were stored in a storage shed on the property. RV was not allowed to fully access these items and, as a result, felt limited in his/her ability to participate in preferred activities. RV was in the facility for longer than 14 days, but did not have a care plan in the RV's records. RV expressed his/her feelings regarding RP1's behaviors toward RV. RP1 responded in an insensitive and offensive manner to RV's expressions of vulnerability. The facility failed to assure resident's rights were maintained. This failure is a violation of Oregon Administrative Rules.",2,,,,Verbal/Mental abuse +RD120294B,522807,AFH,4/6/2012,"It was reported that on or about April 4, 2012, Licensee failed to provide a home-like environment. During an evening in February or March 2012, Resident #1 became upset while watching television in the living room with other residents. Licensee asked Resident #1 to go to his/her room for the evening to prevent disruption to the other residents. Once in Resident #1's room he/she decided he/she did not want to go to bed. Licensee stood in front of Resident #1's bedroom door to prevent him/her from exiting the room. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +PT132473,522837,AFH,10/4/2012,"On or about October 4, 2012, it was alleged that Reported Perpetrator (RP) failed to properly plan care surrounding Reported Victim #2 (RV2). RP was aware that RV2 had a history of violent behavior. RP was aware that RV2 had previously been violent with adult foster home staff. RV2 was upset that a family member did not show up and RV2 began exhibiting behaviors. RP attempted to calm RV2 and RV2 became aggressive toward RP. Reported Victim #1 (RV1) walked passed RV2 and RV2 struck RV1. RV1 did not sustain any injury. As of 3/29/2013 RV2's care plan had not been updated to reflect RV2's behavior. The licensee failed to properly caren plan for RV2. The failure is a violation of Oregon Administrative Rules.",2,0,,, +PT151663,522837,AFH,5/22/2015,"During an Adult protective Service (APS) investigation initiated on May 26, 2015, it was discovered that RV1 had approximately fifteen narcotic medication tablets (_x001A_medication_x001A_) that went missing. Licensee_x001A_s failure to maintain a medication system that prevents theft or a misuse of medications, resulted in a diversion of RV1_x001A_s medication. Licensee_x001A_s failures are a violation of the AFH OARs, is considered financial exploitation, and constitutes abuse.",3,400,,, +ES133817,522860,AFH,7/13/2013,"It was reported that on or about July 23, 2013, Licensee failed to protect Resident 31 (RV1) from loss of medications. RV1 had medication missing, Licensee was unable to determine what happened to the missing medications. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",1,,,, +ES159970,522861,AFH,1/17/2015,"On or about January 20, 2015, the Department received a complaint which alleged the facility had failed to provide appropriate care and services for Resident #1 (RV). At a prior placement, RV was described as a ""good eater"" and usually ate 80 to 100% of the food on his/her plate. RV weighed approximately 220 pounds while in residence there. If RV ate less than 50 percent of his/her meals, RV was given a meal replacement shake. A Patient Discharge/Transfer form dated December 5, 2014, documented that he/she was to be given ""health shakes three times daily"". Licensee's screening and assessment documented on December 5, 2014 did not mention health shakes. The facility care plan for RV dated December 15, 2014 was signed by the Licensee and caregivers. The care plan mentions that RV's general appetite was poor but does not mention a need for nutritional shakes. An evaluation conducted by a registered nurse on January 7, 2015 includes that RV was at risk for weight loss, that he/she should be weighed weekly and to give RV protein powder in milk. Witness #1 (W1) reported that he/she did not purchase nutritional supplements until January 19, 2015. Witness #9 (W9) stated that RV was approximately 206 pounds on or around January 21, 2015, a weight loss of approximately 14 pounds from December 5, 2014 to January 21, 2015. Facility failed to include nutritional shakes in RV's Screening and Assessment or in RV's Care Plan despite the matter having been mentioned in RV's discharge/transfer paperwork from RV's prior facility. Licensee failed to comply with RV's nutrition regimen which resulted in weight loss. Licensee's failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +ES164537,522861,AFH,1/13/2016,"Between 1/30/16 and 2/8/16 RV's prescribed medications were not administored correctly. Between 1/17/16 and 2/8/16 RV's metabolic condition was not monitored. Some of RV's medications delivered to the facility were also misplaced. + +The facility has since closed.",2,,Substantiated,Substantiated,Neglect +MS117764,522866,AFH,8/13/2011,"On or about August 19, 2011, it was reported that Resident #2 (RV2) sustained a skin injury while being assisted by Reported Perpetrator #2 (RP2) in the bathroom on August 13, 2011. It was determined that RP2 had been intoxicated while on duty that day and was unable to safely provide care for the residents of the adult foster home. Resident #1 (RV1) called law enforcement for assistance who then contacted the Licensee. Licensee reported to the facility in order to immediately relieve RP2 from providing care. RP2's employment was terminated the next day.",2,0,Not Substantiated,Substantiated,Neglect +MS129621,522866,AFH,3/22/2012,"On or about March 22, 2012, Witness #2 (W2) went to the adult foster home to visit Resident #1. The residents were eating beef stew for dinner. When Witness #2 saw what the residents were being served for dinner, he/she commented that it looked like vomit. Witness #2 told Resident #3 who is visually impaired that they were being fed dog food. Witness #2 also told Resident #1, #2, and #3 that they would have to move. It was reported that Witness #2 continued with the verbal assaults for approximately two hours. Resident #2 stated that he/she was too upset to eat and was awake all night crying due to the turmoil caused by Witness #2 that evening. Witness #3 was unsure if she had the right to request that Witness #2 leave the foster home. The facility failed to protect residents from inappropriate verbal communication. The failure is a violation of Oregon Administrative Rule.",2,0,,,Verbal/Mental abuse +MS120441B,522866,AFH,7/4/2012,Individually apportioned-SG 6/12/13,3,0,,,Financial abuse +MS120441A,522866,AFH,7/4/2012,6/12/13 SG-Individually apportioned,3,0,,,Financial abuse +BH146978,522874,AFH,4/29/2014,"On April 29, 2014, Licensee and Witness #1 (W1) were assisting Resident Victim #1 (RV1) with a shower. RV1 slipped while in the shower and Licensee and W1 guided RV1 to the floor. Licensee and W1 did not notice any injury at the time of the incident. On April 30, 2014, RV1 began to complain of leg pain. On the evening of April 30, 2014, Licensee told Witness #2 (W2) about the incident and RV1 was moved to another facility. On May 1, 2014, RV1 was found to have a fractured femur. Licensee's failures are a violation of Oregon Administrative Rules is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,400,,,Neglect +NW147132A,522881,AFH,3/20/2014,"It was reported that on or about March 20, 2014, Licensee failed to provide a safe and adequate medication administration system for Resident #1 (RV1). Licensee failed to follow physicians orders for prescribed medication and failed to properly document RV1's administered medications. Licensee's failures are a violation of Oregon Administrative Rules is considered neglect of care and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,800,,,Neglect +NW148360,522881,AFH,8/5/2014,"On or about August 5, 2014, Adult Protective Services (_x001A_APS_x001A_) received a complaint that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Residents Victim #1 (_x001A_RV1_x001A_). + +Reported Perpetrator #1 (_x001A_RP1_x001A_) was responsible for providing care and services to RV1. RV1 developed a serious skin condition while under the care of RP1. Facility staff had documented skin issues as early as June 14, 2014. Additionally, facility records indicate RV1 made multiple suggestions to prevent skin irritation but there was no documentation indicating the RP1 assisted RV1 with any of his/her suggestions. Facility records also indicate facility staff was telling RV1 to get out of his/her power chair every 3 hours but there were no records indicating staff were actively providing RV1 with the needed assistance to get out of his her chair. As a result of RP1_x001A_s failures, RV1 did develop an abscess and stage II skin breakdown and was transported to the hospital on August 4, 2014.",3,400,,,Neglect +CO12014,522890,AFH,11/4/2011,"The licensor conducted a monitoring visit at the licensee_x001A_s Adult Foster Home (AFH) on November 4, 2011. During the visit the licensor discovered that Caregiver #1 had been working in the AFH and did not have an approved criminal records check. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. NOTE: email sent to AR to begin the aging process on 1/10/13",0,200,,, +AL129727,522901,AFH,2/15/2012,"Resident #1 was admitted to Licensee's adult foster home (AFH) for respite care and resided there for five days. Resident #1's General Information and Screening Assessment dated February 11, 2012 indicated that Resident #1's lower legs had poor color and circulation. Witness #1 provided Licensee with specific care instructions in order to prevent the breakdown of Resident #1's skin. Resident #1 developed a pressure lesion during the five days that he/she resided at the AFH. Licensee acknowledged that he/she did not notice that Resident #1 had developed a wound. Facility failed to provide the care and services necessary to maintain the physical health of Resident #1. Facility failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,0,,,Neglect +AL129911,522901,AFH,1/31/2012,"Resident #1 was prescribed a liquid antibiotic to be administered beginning January 31, 2012. Reported Perpetrator #1 did not administer the medication until February 1, 2012. The facility failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rule.",2,0,,, +AL133534,522901,AFH,5/5/2013,"Resident #1 had a physician's order to be administered a sedative medication twice daily at 8AM and 8PM. Resident #1's behavior on or about May 5, 2013 was described as being ""aggressive"". Licensee and Reported Perpetrator #2 dispensed an ""extra"" dose of Resident #1's sedative medication at approximately 10PM. Facility failed to follow physician's orders. The failure is a violation of resident rights, is considered improper use of a chemical restraint and constitutes abuse.",2,,Substantiated,Substantiated,Restraints +AL164396,522901,AFH,1/21/2015,"RP tooki an un-identified amount of medication from RV1 and RV2. RP admitted taking these medications, which were discovered in RP's sock by law enforcement. RP acknowledged being under a great deal of stress, and being distraught over recent events, some of which RP could not remember. RP voluntarily surrendered the facility license and the facility is now closed.",2,,Substantiated,Substantiated,Financial abuse +CO13084,522947,AFH,7/2/2013,"During a renewal inspection conducted on June 26, 2013, Licensor discovered Licensee had unqualified caregiver (T.J. Moli) working alone and providing care to the residents of his/her Adult Foster Home (AFH), prior to having an approved criminal background check as required. Licensee's failures are a vilation or AFH OARs. UPDATE: FOD complete June 05, 2014 and e-mail sent to AR requeting that the AGING PROCESS being.",3,250,,, +BH149161,522954,AFH,10/20/2014,"RV1 was a resident of Licensee's adult foster home. On October 24, 2014, Licensee noticed RV1 was weaker than normal but didn_x001A_t not seek medical treatment for RV1. RV1_x001A_s family arrived at the facility around 3:00 PM on October 24, 2014. While at Licensee_x001A_s AFH RV1_x001A_s family contacted RV1_x001A_s doctor and RV1_x001A_s doctor recommended RV1 be seen at the emergency room. RV1 was transported to the hospital and was found to have suffered a stroke. Wrongdoing on the part of the Licensee was found to be substantiated.",2,400,Substantiated,Substantiated,Neglect +SV118058A,522956,AFH,9/5/2011,"On or about September 5, 2011 RP1 and RP2 admitted a resident without conducting a thorough assessment. They were unable to do an in-person assessment at the resident's current home so they appropriately interviewed the resident's family about the care needs of the resident. However, they made no attempt to verify the information they received with the resident's current caregivers, physician or other informed sources. As a result they admitted the resident without being able to provide appropriate toiletting or behavioral services and placed the resident at risk of harm.",2,0,,, +CO13087,522976,AFH,7/8/2013,"On July 8, 2013, an unannounced visit was conducted at the licensee_x001A_s adult foster home (AFH). During the visit the licensee disclosed to the licensor that caregiver EG had been left alone with residents and was not a qualified caregiver. It was discovered that EG had not completed the orientation to the AFH or the caregiver preparatory workbook as required and was left alone with residents on 7/7/2013. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +HB120288,522978,AFH,5/14/2012,"On or about May 14, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). It was determined through interviews that RV had a prescription for a medication patch to be applied once every 72 hours. RV's prescription was filled on 4/24/12 with a quantity of 10. RV did not receive the medication patch on 5/14, 5/17, 5/20 and 5/23. RP contacted RV's physician on 5/15/12 and attempted to get the medication patch refilled. W1 contacted RV's physician on 5/21/12 and attempted to get the medication patch refilled. The medication patch was refilled on 5/22/12. The licensee failed to administer ordered medication. The failure is violation of Oregon Administrative Rule.",2,0,,, +HB147873,522978,AFH,7/23/2014,"On or about July 23, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from theft of medication. RV was prescribed a narcotic pain medication that contained 30 tablets. RV had been administered one narcotic pain medication. During the morning hours of 7/20/2014 Reported Perpetrator #3 (RP3) reported to RP1 that the reamining 29 tablets of narcotic pain medication was missing. Reported Perpetrator #2 (RP2) and RP3 were the only caregivers on duty between 7/19 and 7/20.",2,,Not Substantiated,Substantiated,Financial abuse +HB147989,522978,AFH,8/1/2014,"On or about August 1, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). On 7/16/2014 it was noted by Witness #2 (W2) that RV's left big tow was swollen and bruised. Witness #1 (W1) believed W2's picture only depicted a small scratch on RV's left 2nd toe due to a previous injury. W2 did not notify W1 that the injury sustained to RV's left big toe was a new injury. RP was instructed by W1 to not contact RV's physician unless it was for an emergency. On 7/26/2014 W1 visited RV and saw RV's big toe. W1 transported RV to the doctor where it was found that RV had sustained a toe fracture. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO13047,523028,AFH,10/5/2012,"On October 5, 2012, Licensee received a notice of violation for having an unqualified caregiver providing care to the Resident_x001A_s at his Adult Foster Home (AFH). According to the resident_x001A_s Medication Administration Records (MARs) and Resident narrative, Caregiver (BD) worked from September 23, 2011 through September 20, 2012, without a criminal background check as required. Licensee failed to have a qualified caregiver present 24 hours per day as required.",2,250,,, +CO12106,523053,AFH,8/24/2012,"On August 24, 2012, the licensor conducted a renewal inspection of the licensee_x001A_s Adult Foster Home (AFH). Upon arrival caregiver MA was working alone in the AFH. The licensor found that MA did not have an approved criminal records check or a completed caregiver preparatory workbook for the AFH. During the inspection caregiver MA stated that she/he had been performing glucose tests and insulin injections for a resident and had not been delegated by a registered nurse to perform these tasks as required. There was no record of delegations at the AFH. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. NOTE: 1/3/13 Final Order by Default completed. Sent to AR person to start Aging process. UPDATE: Sent to DOR for collections on 7/31/13",3,500,,, +MV120775A,523053,AFH,7/31/2012,"On or about July 31, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from financial exploitation. On two separate occasions RV asked Reported Perpetrator #2 (RP2) for a ride to RV's relative's home. RV paid RP2 $5.00 the first trip, and $10.00 the second trip. RP2 accepted money from RV to transport RV to h/her relative's home. It was determined that the licensee failed to protect RV from loss of property. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV120775B,523053,AFH,7/31/2012,"On or about July 31, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to assure Reported Victim (RV) resident rights. Reported Perpetrator #2 (RP2) used derogatory and inappropriate language toward RV. It was determined that the licensee failed to assure RV's resident rights. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV120775C,523053,AFH,7/31/2012,"On or about July 31, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to administer an ordered medication for Reported Victim (RV). Reported Perpetrator #2 (RP2) did not administer a prescribed medication to RV on 7/9/12, 7/10/12, and 7/11/12. RP2 did not administer RV's morning medications on 7/10/12. It was determined that the licensee failed to administer ordered medications to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV132559,523053,AFH,2/3/2013,"On or about February 3, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from theft of h/her medication. RV had a physician order for Clonazepam to be administered three times daily. RV had multiple re-fills on this prescription. RV's medication administration record (MAR) indicates that RV missed thirty doses of this medication. The licensee failed to administer an ordered medication to RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO14050,523053,AFH,3/7/2014,Condition Withdrawn on 5/2/14,4,,,,Sexual abuse +MV146721,523053,AFH,4/11/2014,"On or about April 14, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from financial exploitation. When RV moved into the adult foster home, RV had h/h debit card locked in the medication cabinet for safe keeping. On 4/11/2014 Witness #1 (W1) was approached by Witness #2 (W2) and Witness #3 (W3) with conerns that per RV's bank statement, charges were made in excess of $400.00 from Rv's account. The items purchased were things that RV would not normally purchase. RP2 acknolwedged to W2 and W3 that he/she had used RV's debit card for h/h own purposes and agreed to repay RV over time. The incident was referred to law enforcement.",3,,Not Substantiated,Substantiated,Financial abuse +WB146888,523053,AFH,4/5/2014,"On or about April 24, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe medicaiton administration system for Reported Victim (RV). RV does not have an order to self administer his/her medication. In February, 2014, RV left the facility with a relative and was provided enough medication for two scheduled administrations. RV returned to the facility without having taken any of his/her medication. RV had left the medications in his/her travel bag. The travel bag with RV's medication was discovered after RV had been transferred to another facility. RP failed to provide a safe medication administration for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +GP147119B,523062,AFH,5/19/2014,"On or about May 19, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). Reported Perpetrator #2 (RP2) acknowledged that he/she administered a medication (benzodiazepine) differently than as prescribed. The medication administration record shows that RP2 administered twice the amount of benzodiapezine as prescribed at least five times. The licensee failed to provide a safe medicaiton administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +GP134800,523101,AFH,10/21/2013,"On or about October 22, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RP ""yelled"" at RV on multiple occasions and has been ""condescending"" toward RV. On at least one occasion RP threatened RV to ""stop it or RV will have to move out."" RP acknowledged that he/she told RV that if RV does not stop being mean or demanding to RP than he/she can look for another place to live. The licensee failed to protect RV from inappropriate verbal comments. The failure is a vioalation of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +CO12009,523132,AFH,1/5/2012,"The licensor made a home visit to the licensee_x001A_s Adult Foster (AFH) Home on January 12, 2012, in response to an email that indicated there was an unqualified caregiver providing care in the AFH. During the visit the visit the licensor confirmed that caregiver #1 did not have an approved criminal records check and was left alone to provide care to residents. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules. NOTE: email sent to AR to begin the aging process 1/10/2013.",3,250,,, +CO14229,523150,AFH,11/3/2014,"Provider had gas can left on driveway approximately 5 feet from smoking area, per provider's own admission. Home caught fire. Both residents were evacuated safely. One has alternate placement. One is now in a hotel where provider is continuing to provide care. Local office requested condition.",3,,,, +CO15176,523150,AFH,8/25/2015,"Caregiver was working outside the facility, with baby monitor, and passed out. Licensee was notified and called an unqualified caregiver to come to the home to provide care instead of back up provider.",3,250,,, +PT164480A,523150,AFH,1/14/2016,"On or about January 14, 2016, the Department received a complaint which alleged the Licensee had failed to provide a safe environment for Resident #1 (RV1) and Resident #2 (RV2). During the course of the investigation, APSS (Adult Protective Services Specialist) observed RV1 wearing wrinkled clothing, an unbuttoned shirt and slippers on opposite feet. RV1 also had uncombed hair and needed a shave. Witness #6 (W6) and Witness #7 (W7) reported that RV2_x001A_s hygiene had declined. RV2 had dirty hair, needed a haircut and his/her clothes had not been laundered. + +On February 2, 2016, during an unannounced visit, APSS noted that RV1_x001A_s room had an offensive odor, the bed sheets were visibly soiled and a pile of dirty clothes on the floor. There was also an open trash receptacle that was overflowing with soiled undergarments. + +Additionally, RV1 reported that Licensee shouted and scared him/her when Licensee told RV1 that he/she would be sent to another facility; RV2 reported that Licensee would become upset when RV1 needed assistance during the night; RV2 also stated that Licensee spoke gruffly to him/her and that Licensee could go from being nice to being a, _x001A_witch on a broomstick._x001A_ Both RV1 and RV2 reported that Licensee and W11 had fought in front of the residents. + +The APS investigation also included information from Two Rivers Correctional Institution indicating that during a recorded visit, a person believed to be Licensee stated that she and W11 needed to stop using methamphetamines. In the report, three witnesses, Witness #2 (W2), Witness #5 (W5) and Witness #8 (W8), reported that Licensee was a known drug user and Witness #3 (W3) and W5 reported that Licensee associated with known drug users at her AFH. + +Based on interviews and observations, APSS determined that Licensee had failed to take precautions against conditions that would threaten the health, safety and welfare of residents, failed to provide appropriate care and services to all residents of the AFH, and failed to maintain a home-like environment. Licensee_x001A_s failure to provide a safe environment is a violation of residents_x001A_ rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +PT164953A,523150,AFH,2/25/2016,"On or about March 3, 2016, the Department received a complaint which alleged the facility had failed to provide adequate care and services for Resident #1 (RV1) and Resident #2 (RV2). RV1 and RV2 had recently moved from Licensee_x001A_s adult foster home (AFH) to another care setting. + + + +During the course of the investigation, Witness #1 (W1) and Witness #2 (W2) reported to the Adult Protective Services Specialist (APSS) that RV1 had lice crawling all over his/her head when RV1 admitted to the new care setting. W1 stated that he/she felt particularly bad for RV1 since RV1 was not capable of raising his/her arms up and therefore, could not have scratched his/her head, _x001A_it must have been driving [him/her] nuts_x001A_. RV1 stated that at Licensee_x001A_s AFH, he/she had received one bath in approximately three weeks, and a few times he/she received one bath per week. RV1 was care planned to receive a bath two times per week and additional bathing assistance as needed. RV1 was also care planned to have his/her hair washed by a caregiver a minimum of two times per week and additional shampoos as needed. + + + + + +W1 also reported that although RV2 did not have lice at the time of his/her admission to RV2_x001A_s new care setting, it was evident that he/she had not been showered in a long time. Furthermore, W1 also stated that RV2_x001A_s clothes were dirty and smelled strongly of body odor. RV2_x001A_s care plan was reviewed. The care plan indicated that RV2 was to receive bathing services two times per week and receive additional bathing assistance as needed. RV2_x001A_s care plan also addressed the frequency of hair washing which was listed as two times per week and additional shampoos on an as needed basis. RV2 reported to APSS that _x001A_RP kind of quit giving me a bath_x001A_ or did so _x001A_maybe every week or two._x001A_ + + + +Additionally, RV1, RV2 and Licensee all acknowledged that there were mice inside the AFH. RV1 stated that [they] caught four or five of them but there were still more. RV1 further shared that it got to the point where he/she was naming the mice. W1 reported that RV1 had told him/her that they were running on top of RV1_x001A_s bed and RV2 acknowledged that he/she had seen a mouse running loose in the laundry room. + + + +Licensee failed to follow RV1 and RV2_x001A_s documented care plans and failed to take reasonable precautions to prevent rodents from the AFH. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +PT164953C,523150,AFH,2/25/2016,"On or about March 4, 2016, the Department received a complaint which alleged the facility had failed to protect RV1 and RV2 from loss of property. + + + +During the course of the investigation, RV1 reported to the Adult Protective Services Specialist (APSS) that he/she had some clothing items and slippers that disappeared during the time RV1 resided at Licensee_x001A_s adult foster home. + + + +RV2 owned a television at the time the AFH experienced a fire in November of 2014. Afterwards, the television was taken from the AFH to be cleaned or replaced. The television was never cleaned and returned, or replaced. + + + +Licensee failed to protect RV1 and RV2 from theft of property. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered financial exploitation, and constitutes abuse.",3,,Substantiated,Substantiated,Financial abuse +NB135309,523151,AFH,12/6/2013,"Pharmacy #1 delivered approximately 730 tablets of a narcotic pain medication for Resident #1 between May 2013 and October 2013 to licensee's adult foster home (AFH). Pharmacy #2 delivered a total of 12 tablets of a narcotic pain medication for Resident #1 to the AFH on June 12, 2013. Resident #1 reported that he/she did not take any prescribed pain medications. On December 6, 2013, Reported Perpetrator #2 (RP2) stated that Resident #1 did not take any narcotic pain medications and that Resident #1 did not receive an order for narcotic pain medication while RP2 was working at the AFH. However, a medical visit report for Resident #1 indicated that on or about May 13, 2013, Reported Perpetrator #2 requested a prescription for narcotic pain medication for Resident #1. The narcotic pain medication delivered from the pharmacies was not listed or charted on Resident #1's Medication Administration Records. Records obtained from Yellow Cab Taxi showed that Reported Perpetrator #3 (RP3) signed for the June 2013 delivery from Pharmacy #2. During the course of the investigation, it was also discovered that the inventory form for Resident #2_x001A_s narcotic medication did not match the number of remaining pills in Resident #2's narcotic pain medication bottle. Facility failed to protect Resident #1 from loss of medication. This failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +MS133936,523156,AFH,7/29/2013,"It was reported that on or about July 29, 2013, Licensee failed to provide a safe medication administration system for Resident #3. Witness #8 was administering to Resident #3 the incorrect dose of his/her medication. Licensee's failure is a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO12023,523158,AFH,1/31/2012,"The licensor conducted a monitoring visit on January 31, 2012, at the licensees Adult Foster Home (AFH). During the visit the licensor discovered that the smoke alarm at the top of stairway did not have a battery installed and was not functional. The licensee failed to maintain a smoke alarm in functional condition. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +RS134566,523158,AFH,9/24/2013,"On or about September 24, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe medication administration system for Reported Victim (RV). RV has a prescription for Reported Perpetrator #2 (RP2) stated that RV was missing one pain medication pill in July 2013, and three pain medication pills in August 2013. RV's medication administration record (MAR) was not initialed for the morning pain medication on October 11, 2013. The licensee failed to provide a safe medication administration system for RV. The failure is a violation of Oregon Administrative Rule.",2,,,, +RS146356,523158,AFH,3/11/2014,"On or about March 12, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim #1 (RV1) and Reported Victim #2 (RV2). RV1 had been living at the facility for approximately one year. RV1 has exhibited previous behaviors and had been seeing a behavioral specialist and intensive case manager to address the behaviors. RV1 does not like RV2. A behavior support services plan had been set in place that RV1 and RV2 agreed to follow. During an incident after the behavior support plan was in place, RV2 walked into RV1 and RV2's bedroom. RV1 asked RV2 to leave. RV2 told RV1 ""no"" and RV1 slapped RV2 across the cheek. Shortly after this incident, RV2 was passing by RV1 in the hallway when RV1 slapped RV2 across the arm. Another behavioral support service plan was created following these incidents. The licensee failed to provide a safe environment for RV1 and RV2. The failure is a violation of Oregon Administrative Rules.",2,,,, +RB146685,523158,AFH,4/8/2014,"On or about April 10, 2014, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from rough treatment. RV2 struck RV1 in the face. RV2 stated that he/she did not remember hitting RV1. Witness #1 (W1) observed a red mark on RV1's face. RV2's behavior plan dated 3/4/2014 notes RV2 is not to go into roommates living area, no fighting, no name calling, and to walk away if roommate is bothering RV2. The licensee failed to follow RV2's behavior plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +KF152106,523171,AFH,7/16/2015,"It was reported that on or about July 16, 2015, Licensee failed to protect Resident #1 (RV1) from misappropriation of funds. Licensee collected money for RV1's room and board and care services that Licensee was not entitled to as RV1 was in the hospital. Licensee did return RV1's money to his/her family. Licensee's failures are a violation of OARs, is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Financial abuse +RD146190,523180,AFH,2/24/2014,"On or about February 26, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2) and Reported Victim #3 (RV3) from misappropriation of medication. Witness #1 (W1) noticed that RV's narcotic pain medications did not look normal. W1 contacted RP1 who confirmed that RV's narcotic pain medications were incorrect. RP1 notified law enforcement. Law enforcement responded and questioned Reported Perpetrator #2 (RP2). RP2 admitted to taking narcotic pain medication from RV1, RV2 and RV3 between the months of December, 2013 and February, 2014. RP2 replaced approximately 25 of RV1's bottled narcotic pain pills with over the counter pain pills. RP2 replaced approximately 30-50 of RV2's bottled narcotic pain pills with over the counter pain pills. RP2 replaced approximately 60 of RV3's narcotic pain pills in bubble packs with over the counter pain pills.",3,,Not Substantiated,Substantiated,Financial abuse +MS129108,523190,AFH,1/22/2012,"It was reported that on or about January 22, 2012, Licensee failed to provide a safe medication administration system. Reported perpetrator #1 (RP2) was providing care to Resident #1 (RV1) when RV1 passed. After RV1 passed RP2 disposed of RV1's narcotic pain medication by pouring it down the toilet. RP2 took RV1's name off the bottles and shredded RV1's name then rinsed the bottles and threw them in the trash. Licensee failed to ensure RV1's medication was disposed of according to the requirements of the Adult Foster Home local DEQ waste management and failed to have a record of the disposal of RV1's narcotic medication. Licensees failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MS135392A,523190,AFH,12/16/2013,"It was reported that on or about December 16, 2013, Licensee failed to provide appropriate care to Resident #1. Licensee and Reported Perpetrator #2 (RP2) failed to provide the necessary care and services to Resident #1. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee and RP2 was substantiated.",2,,Substantiated,Substantiated,Neglect +MS135392B,523190,AFH,12/16/2013,"It was reported that on or about December 16, 2013, Licensee failed to provide a safe medication administration system for Resident #1.Licensee failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +AS118604,523200,AFH,12/2/2011,"On December 1, 2011, Reported Perpetrator #2 (RP2) checked Reported Victim_x001A_s (RV) blood sugar level (BSL). RV_x001A_s BSL was 84. RP2 administered seven units of insulin. According to the physician order, RV was not to be administered the seven units of insulin if RVs BSL was below 100. RP2 was not delegated to administer insulin to RV. After the insulin was administered RV sustained a fall. RV_x001A_s BSL was checked again after the fall by RP1. RV_x001A_s BSL was 26. Emergency services were contacted and RV was transported to the hospital. The facility failed to provide appropriate care and services. The failures are violation of resident rights, are considered neglect of care and constitute abuse. NOTE: email sent to AR to begin the aging process on 1/10/13",3,400,,,Neglect +AS129640,523200,AFH,3/17/2012,"On or about March 17, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from misappropriation of RV's personal incidental funds (PIF). It was determined that RP handled RV's PIF. RP did not keep any receipts on what RV's PIF was spent on. The licensee failed to assure RV's resident rights. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AS129682,523200,AFH,3/28/2012,"On or about March 28, 2012, it was alleged that Reported Perpetrator (RP) failed to administer an ordered medication to Reported Victim (RV). While RV was at a separate facility RV's primary physician ordered that RV's narcotic pain medication be lowered from 40mg to 20mg. When RV arrived back at RP's facility, RV did not have the physician order to change the dosage of the medication. RP had already destroyed what was left of RV's 40mg narcotic pain medication. RV did not receive h/h narcotic pain medication for several days. RV experienced episodes of pain during the time h/she did not have h/h narcotic pain medication. The licensee failed to administer an ordered medication to RV. The failure is a violation of resident rights, and constitutes abuse.",2,0,,,Financial abuse +AS118664,523201,AFH,12/7/2011,"On or about December 7, 2011, it was alleged that Reported Perpetrator (RP) failed to administer medication as ordered to Reported Victim (RV). RV had a doctor order to self administer h/h medications. RV's physician order stated that RV was to receive 0.25ml of morphine 2x daily. RP had been assisting RV administer RV's morphine since h/she was admitted into the facility. RP was administering 1ml of morphine to RV. RV was transported to the hospital due to overdosing on morphine. The licensee failed to administer medication as ordered to RV. The failure is a violation of Oregon Administrative Rule.",3,0,,, +CO15177,523208,AFH,8/27/2015,Limited adult foster home provider left resident unattended while out of the house receiving training. Mandatory civil penalty.,3,250,,, +CO15213,523208,AFH,10/5/2015,Resident in a limited AFH left alone.,3,300,,, +BH120950,523261,AFH,8/6/2012,"On or about August 6, 2012, Licensee reported to Witness #2 that Resident #1 does not eat vegetables. Witness #2 disagreed with Licensee's statement regarding Resident #1's eating habits. Licensee reported he/she was ""sick and tired"" of being doubted by Witness #2. The conversation took place in front of Resident #1. The facility failed to treat Resident #1 with respect and dignity. The failure is a violation of Oregon Administrative Rule.",2,0,,, +BH121774,523261,AFH,9/21/2012,"On or about September 21, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV has some cognitive impairnment and is a known wander risk. RP has a door alarm in place to notify RP if RV wanders. RP acknowledged turning the door alarm off. RV wandered out into a busy street and fell. As a result of the fall RV sustained injury to h/her face. The licensee failed to provide a safe environment for RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +CO14119,523271,AFH,7/1/2014,"On August 16, 2013, the local licensing authority (LLA) received a renewal application from the licensee. The application listed (EF) as a substitute caregiver. On October 29, 2013, the LLA reviewed the Office of Inspector General_x001A_s data base and discovered EF on the exclusion list with indefinite termination. On November 4, 2013, the LLA issued a letter to the licensee informing the licensee that EF could no longer work in the adult foster home (AFH) due to EF being on the exclusion list. On December 30, 2013, the LLA received copies of medication administration records (MAR) with EF_x001A_s initials as administering medication, and progress notes for November 2013 and December 2013 that had EF_x001A_s initials at the end of the narrative entries. + + + +On April 22, 2014, a monitoring visit was conducted at the licensees AFH. Upon arrival the licensee, EF and caregiver LM were on duty. On May 28, 2014, the LLA received copies of registered nurse delegations that listed EF as being delegated for a resident in the home. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. On June 10, 2014, a monitoring visit was conducted at the licensee_x001A_s AFH. Upon arrival caregiver AW was the only care giver on duty. On July 1, 2014, the licensor discovered AW_x001A_s criminal background check was denied on June 30, 2014. AW had been working in the AFH without a criminal background check. On July 1, 2014, the licensee was notified that AW could no longer work in the AFH. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,450,,, +MV147824C,523271,AFH,7/18/2014,"On or about July 21, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RV entered the facility with financial issues. RP had RV sign a power of attorney over to RP, allowing RV to have the authority to manage RV's financial affairs. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV148423,523271,AFH,8/25/2014,"On or about September 4, 2014, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from financial exploitation. RP became RV's power of attorney (POA) on 2/5/2013 while RV was a resident at the adult foster home (AFH). RP put his/her name on RV's bank account. RV stated that he/she did not agree to have RP be RV's POA. RV has requested that RP be removed as POA and stated that RP is still receiving RV's money. RP is named as executor of RV's will, RV's spouse as secondary executor, and RP's children as bequests of property dated 2/5/2013. The licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights and constitutes abuse.",2,,,,Financial abuse +RD129064,523280,AFH,1/7/2012,"It was reported that on or about January 7, 2012, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee failed to follow Resident #1's (RV1) care plan and failed intervene after RV1 had fallen. Licensee's failures are a violation of Oregon Administrative Rule, are considered neglect and constitute abuse. Wrongdoing on the part of the Licensee has been substantiated.",2,0,,,Neglect +MV133503,523286,AFH,6/12/2013,"It was reported that on or about June 12, 2013, Licensee failed to provide appropriate care and services to Resident #1. Licensee admitted Resident #1 without the required documentation and medication. Licensee admitted Resident #1 on June 12, 2013 and did not get the proper documentation and medication for Resident #1 until June 14, 2013. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +RB121417,523299,AFH,10/22/2012,"On or about September 21, 2012, Resident #1 (RV) was admitted to the licensee_x001A_s adult foster home (AFH). Reported Perpetrator (RP) was aware that RV had some skin breakdown on RV_x001A_s buttocks upon arrival at RP_x001A_s AFH. Shortly after RV_x001A_s arrival RP began to apply ointment to RV_x001A_s skin breakdown, and wrapped the breakdown in saran wrap. RP did not obtain a physician_x001A_s order for treatment of RV_x001A_s skin breakdown. + + + +According to RV_x001A_s care plan, RV was to be turned/ re-positioned every two hours. RP_x001A_s narratives indicate that on 10/09/2012 RV was repositioned three times, on 10/10/2012 RV was repositioned two times, and on 10/11/2012 RV was repositioned two times. On October 15, 2012, RV was transported by emergency personnel to the hospital for treatment. Upon admission to the hospital, RV was unresponsive and dehydrated. The hospital discharge sheet showed that RV had a stage II pressure wound on h/her right buttock, a wound on h/her right shoulder (stage unknown), and a stage I pressure wound on h/her left heal. The licensee failed to seek timely medical attention for RV, which resulted in RV_x001A_s condition to worsen. The licensee_x001A_s failure is violation of Oregon Administrative Rule and constitutes abuse. UPDATE: Staffed with supervisor. Did not rise to level of CP. CP was not sent out. 2/8/13",2,400,,,Neglect +CO13113,523362,AFH,9/10/2013,"It was reported that on or about May 30, 2013, Licensee hired Caregiver #1 to work in her Adult Foster Home prior to having the required background check approval. Caregiver #1 started working in Licensee's Adult Foster Home AFH on September 3, 2013 and was left alone to care for the residents of the AFH. Caregiver #1's background check approval was adated for November 13, 2013.",3,250,,, +AL145700,523362,AFH,4/3/2013,"It was reported that on or about April 3, 2013, Licensee failed to ensure Resident #1's (RV1) medication was administered as ordered. Reported Perpetrator #2 (RP2) had administered RV1's as needed narcotic medication on a scheduled basis every 6 hours. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",1,,,, +AL145735,523362,AFH,5/9/2013,"It was reported that on or about May 9, 2013, Licensee failed to administer medications as ordered. On May 9, 2013 and May 12, 2013, Reported Perpetrator #2 (RP2) failed to follow hospice delegation orders resulting in an overdose of Resident #1's medication. Licensee's failures are a violation of Oregon Administrative Rules. RP2's failures are considered neglect and constitute abuse.",3,,Not Substantiated,Substantiated,Neglect +AL151133B,523362,AFH,1/20/2015,"On or about February 12, 2015, Adult Protective Services (""APS"") received a complaint that RP3 threatened RV. During the course of the investigation, APS substantiated the following; RP3 threatened RV with police, stating RP3 would call law enforcement. RP3 did not know how to work with RV and was more rigid with RV and used manipulation. RP3's actions were a violation of resident rights and are considered a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated, +AL151195,523362,AFH,1/31/2015,"On or about February 2, 2015, Adult Protective Services received a complaint that the facility failed to properly use a restraint. During the course of the investigation, APS substantiated the following: RV must be toiled a minimum of 2 hours per day and must be attended while toileting. RV could remain on the toilet anywhere from 45 minutes up to an hour or longer. Unauthorized restraints were installed in the facility. RP2 instructed staff to use the restraints and assist the RV when toileting if needed. RP did use unauthorized restraints on RV for toileting. RP1 did not have an assessment or doctor orders authorizing use of restraints and could provide no documentation to support authorization of the restraint device as required by OAR. RP1's failure to have an assessment and doctor orders is a failure of OAR. RP2's instructions to staff to use the restraints, without doctor orders or assessment, and use of the restraint is a violation of resident rights, is considered a wrongful use of physical restraint, and constitutes abuse.",3,,Substantiated,Substantiated,Restraints +CO15158,523362,AFH,8/11/2015,"Licensee received a violation for failure to have a nurse to delegate tasks. As part of her correction, she submitted a statement from a nurse and a billing invoice from that same nurse. The statement indicated the last time the nurse consulted was months prior. Three months after the violation, the local licensing authority found a delegation form for insulin injection of one of the residents. It appeared to be unlike what the local authority had seen before. After sending it to the state nurse and the state board of nursing, it appears that the delegation form was not authored by the nurse, although it has a signature of the nurse's name. Falsification of records is a mandatory civil penalty.",3,400,,, +AL151133C,523362,AFH,1/20/2015,"On or about Feb. 2, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to provide adequate hygiene care. During the course of the investigation, APS substantiated the following: RV's care plan indicates that RV is resistive to toileting and will sit in urine soaked bedding or clothes unless cued to do otherwise. On Feb. 12, 2015, RV's disposable briefs/underwear were changed at 9:30 a.m. At approximately 4pm, RV was found sitting in his/her wheelchair with 2 disposable briefs/underwear full of RV's fecal waste and urine and his/her night clothes were soiled. RP2 was found in the AFH living area using his/her phone and unaware of RV's condition. RP2 was informed of RV's condition by W2 and then RV was cleaned. RP2's actions are considered a violation of resident rights, is considered neglect, and constitutes abuse. RP1 stated it was possible the staff was newer and not adequately trained regarding RV's hygiene care. RP1's actions are a violation of OAR.",2,,Not Substantiated,Substantiated,Neglect +AL151133D,523362,AFH,1/20/2015,"On or about Feb. 13, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to prevent a fall with injury. During the course of the investigation, APS substantiated the following: on or about Feb. 13, 2015, RP2 left RV standing by the sink brushing his/her teeth, unassisted in the bathroom, while getting RV's walker, and RV fell. RV suffered an L3 fracture and was taken to the hospital to be evaluated. RV is required to have a staff member perform standby assist while ambulating and for transfers. RP2's failure to follow the care plan regarding standby assistance is a violation of resident rights, constitutes neglect, and is considered abuse. The last updated care plan was October 21, 2013. RP1 did not timely update the care plan. RP1's actions are a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Neglect +CO14204,523363,AFH,9/25/2014,Refer to Revocation #AFHRV14-010,3,,,, +MV132896,523380,AFH,4/8/2013,"It was reported that on or about April 8, 2013, Licensee failed to provide proper care to Resident #1 (RV1). RV1's care plan stated he/she was in need of two person assistance with transfers. On April 8, 2013, RV1 ""needed to get up and when tried to get up fell"" by his/her bed. RV1 got into the kneeling position and called for help. Licensee did not assist RV1 in getting up and left RV1 on the floor for at least a half hour. Licensee's failures are a violation of Adult Foster Home (AFH) Oregon Administrative Rules (OARs), is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +CO13099,523380,AFH,8/12/2013,Suspension issued,4,,,,Physical Abuse +MV134093B,523380,AFH,8/8/2013,"It was reported that on or about August 8, 2013, Licensee failed to protect Resident #1 (RV1) from physical abuse. On a daily basis, out of anger, Licensee would push RV1 into the kitchen table with force causing RV1 to be in pain. On one occasion, Licensee ""disciplined"" RV1 for accidentally running over his/her catheter hose with his/her wheelchair. Licensee ""disciplined"" RV1 by placing RV1 on his/her knees for over an hour, causing RV1 to be in pain.",3,,,,Physical Abuse +MV134093C,523380,AFH,8/8/2013,"It was reported that on or about August 8, 2013, Licensee failed to Protect Resident #1 (RV1) from verbal and emotional abuse. Licensee regularly referred to RV1 as ""douche bag"" a ""waste of space"", ""Stupid retard"" and ""stupid fucking retard"". Licensee's failures are a violation of Oregon Administrative Rules and is considered verbal/mental abuse.",3,,,,Verbal/Mental abuse +MV134093A,523380,AFH,8/8/2013,"It was reported that on or about August 8, 2013, Licensee failed to protect Resident #1 from financial exploitation. Licensee regularly took and smoked Resident #1's medical marijuana. On several occasions Licensee gave Witness #8 (W8) Resident #1's medical marijuana to smoke. On several occasions Licensee gave Resident #1 prescribed pain narcotic to Witness #7 (W7). Licensee failures are a violation of Oregon Administrative rules, is considered financial exploitation and constitutes abuse.",3,,,,Financial abuse +AL145954,523396,AFH,1/5/2014,"On January 5, 2014, Reported Perpetrator #2 (RP2) was the only caregiver on duty at the licensee's adult foster home (AFH). RP2 left the residents alone at the AFH without another qualified caregiver on duty. RP2 acknowledged that he/she left the residents alone at the AFH for at least one hour while he/she picked up a friend in a different city. RP2 stated that it was his/her fault and that he/she shouldn't have done it. The licensee's conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +AL152563A,523396,AFH,9/24/2014,"On or about September 24, 2014, the Department received a complaint that alleged the facility had failed to protect Resident #1 (RV) from verbal intimidation. During the course of the investigation, the Adult Protective Services Specialist (APSS) discovered that Reported Perpetrator #2 (RP2) consistently used a loud voice when he/she communicated with RV. RV became upset, anxious and fearful of RP2. The investigation concluded that RP2's conduct constituted verbal/emotional abuse as defined in 411-020-0002(1)(d)(ii). Licensee (RP1) failed to ensure a home-like environment, failed to ensure that RV received appropriate care and services and failed to provide a safe and secure enviroment. Licensee's failures violate Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +AL152563B,523396,AFH,9/24/2014,"On or about September 24, 2014, the Department received a complaint that alleged the facility had failed to protect Resident #1 (RV) from rough treatment. During the course of the investigation, RV stated to the Adult Protective Services Specialist (APSS) that Reported Perpetrator #2 (RP2) had grabbed his/her nose and twisted it when RP2 cleaned his/her face. RV also reported that RP2 had shaken his/her head and that it had happened on more than one occasion. During the investigation, RV stated that he/she had experienced pain when RP2 cleaned his/her face. The facility advised RP2 to be gentle with RV, especially when cleaning RV's face. The investigation concluded that RP2's conduct constituted rough treatment as defined in Oregon Administrative Rule 411-020-0002(1)(a). Licensee failed to provide a safe and secure environment for RV. Licensee's conduct is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Physical Abuse +CO14163,523422,AFH,8/21/2014,Unqualified caregiver working alone..,3,250,,, +AS121100,523440,AFH,9/12/2012,"On or about September 12, 2012, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). It was found on September 9, 2012, RV was missing 14 of 30mg and 8 of 15mg narcotic pain medication. RV did not go without h/h narcotic pain medication. The licensee failed to provide a safe medication administration system for RV. The failure is a violation of Oregon Administrative Rules.",2,0,,, +DA152768A,523452,AFH,9/1/2015,"On or about September 10, 2015, Adult Protective Services received a complaint that the facility failed to assess and intervene. During the course of the investigation, APS determined that RV has a history of agitation and aggression. RV's care plan lists no interventions to prevent aggression. W6 was sitting on the couch, when RV went after W6, but did not make physical contact with W6. RP2 is a mandatory reporter, but did not notify a law enforcement agency because RP2 felt that he/she could handle RV's behaviors. RP2's failure to care plan, failure to maintain a safe and secure environment, and failure to report abuse is a violation of resident rights, constitutes neglect, and is considered abuse.",2,,Substantiated,Substantiated,Neglect +AL116091,523485,AFH,10/7/2010,Reported Perpetrator failed to keep the medication cabinet secure and did not have a medication accounting and reconciliation system. 60 doses of Resident #1's pain medication were found to be missing. The medication was refilled the following day and the resident did ot miss any doses.,2,0,,, +AL134430,523489,AFH,7/15/2013,"It was reported that on or about July 22, 2013, Licensee failed to protect Resident #1 (RV1) from mental and emotional abuse. Licensee called 911 when RV1 refused his/her medications. Licensee and Reported Perpetrator #2 (RP2) refused RV1 his/her right to use the telephone and his/her right to have visitors as a result of his/her refusal to take a medication. RV1 reported feeling upset, intimidated, emotionally drained and demeaned. Licensee's and RP2's failures are a violation of Oregon Administrative Rules (OARs) and is considered mental abuse. Wrongdoing on the part of Licensee and RP2 was substantiated.",3,400,Substantiated,Substantiated,Verbal/Mental abuse +RB120015,523495,AFH,5/6/2012,"On or about May 6, 2012, Resident #1 (RV1) experienced a fall in his/her bedroom and sustained a skin tear on RV1's left forearm and a bruise on his/her left wrist. The fall occurred when RV1 was attempting to retrieve his/her portable urine collection device that had fallen off his/her wheelchair. The Licensee was unable to get RV1 off the floor alone and emergency services were contacted to provide assessment for injury and to return RV1 to his/her wheelchair. During the course of the investigation, it was found that the Licensee had failed to perform the required pre-admission screening in order to assure the prospective resident's needs could be met at Licensee's adult foster home. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RB120017,523495,AFH,5/7/2012,"On or about May 6, 2012, Resident #1 (RV1) experienced a fall in the bathroom when he/she attempted to transfer him/herself from his/her wheelchair to the toilet. RV1 reported no injuries. The Licensee was unable to lift RV1 from the floor and emergency services were called to assist. The investigation found that the Licensee had failed to perform and document the required pre-admission screening in order to assure the prospective resident's care needs could be met. The failure is a violation of Oregon Administrative Rule.",2,0,,, +RB146944,523495,AFH,4/25/2014,"On or about April 26, 2014, Resident #1 (RV1) experienced an un-witnessed fall. The facility contacted 911 when RV1 complained of intense pain. RV1 was transported to the hospital where he/she was diagnosed with a fractured bone. The previous day, on or about April 25, 2014, RV1 was found on the floor approximately three times. RV1_x001A_s progress notes were reviewed during the investigation. The entries indicated that RV1 had exhibited increasing night-time behaviors in the weeks prior to RV1_x001A_s fall with injury. The facility failed to complete an incident report for RV1_x001A_s fall that took place on or about April 26, 2014. There were no records that indicated the facility had attempted to contact RV1_x001A_s medical professional(s) when RV1_x001A_s condition changed. Licensee failed to intervene when there was a change in RV1_x001A_s health status. Licensee_x001A_s failure is a violation of resident rights, is considered neglect, and constitutes abuse.",3,,,,Neglect +NB120203,523500,AFH,6/1/2012,"It was reported that on or about June 1, 2012, Licensee failed to provide a safe environment for Resident #1. Resident #1's debit card had several unauthorized transactions that occurred on May 31, 2012, and June 1, 2012. Reported perpetrator #2 confessed to taking Resident #2's debit card and making the unauthorized purchases. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,Not Substantiated,Substantiated,Financial abuse +DL147914,523532,AFH,7/24/2014,"On or about 7/24/14, an allegation was made that the facility failed to provide care. During the course of the investigation, APS determined that there were occupants in the home who had not met the requirements for criminal history checks. Licensee was absent from the home for eight days while an authorized caregiver provided care. The home was dirty, cluttered, and entry ways blocked. Facility did not have a working smoke alarm installed in the resident's bedroom. Facility did not have a working lamp or light in RV's room and RV used a flashlight as a lamp. The phone was disconnected and unavailable for use during the home visit. These actions are a violation of OAR and resident rights, constitute neglect, and are considered abuse.",3,500,,,Neglect +DL164330,523532,AFH,1/19/2016,"It was reported that on or about January 19, 2016, Licensee failed to provide care to Resident #1. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +ES133864,523537,AFH,7/15/2013,"It was reported that on or about July 19, 2013, it was reported that Licensee failed to protect Resident #1 from inappropriate and threatening behavior. Reported Perpetrator #2 (RP2) attempted to start a fight with Resident #1. RP2 became physically and verbally aggressive with Resident #1. Wrongdoing on the part of the Licensee was substantiated.",3,,Not Substantiated,Substantiated,Verbal/Mental abuse +ES149039,523537,AFH,10/23/2014,"On or around 10/24/14, APS received an allegation that the facility failed to provide a safe environment. During the course of an investigation, W1 overheard RP2 telling both RV1 and RV2 not to speak with the APS investigator. RP2 admitted that he/she told both RV1 and RV2 not to talk with APS. RV2 expressed that if RP1 thought RV2 spoke with APS, RP1 would raise the rent or kick RV2 out of the home. RV1 and RV2 are dependent upon RP1 and RP2 for their care. RP2's actions are a violation of Oregon Administrative Rules, including rules surrounding resident rights.",1,,,, +AS134000,523542,AFH,7/30/2013,"It was reported that on or about July 30, 2013, Licensee failed to protect Resident #1 (RV1) from financial exploitation. Reported Perpetrator #2 (RP2) was arrested for taking RV1's checkbook out of his/her room and forging two check totaling $85.00. RP2 was charged with negatiating a bad check, theft 2 and criminal possession of a forged document. RP2's failures are considered financial exploitation and constitute abuse. Licensee's failures are a violation of Oregon Administrative Rules (OARS).",2,,Not Substantiated,Not Substantiated,Financial abuse +AS145891,523542,AFH,1/22/2014,"It was reported that on or about June 27, 2012, Licensee failed to Protect Resident #1 (RV1) from misappropriation of RV1's assets. Licensee purchases a trailer from RV1 for $700.00. Licensee only paid $240.00 OF THE $700.00 owed to RV1. Licensee has failed to provide documented proof of paying the full $700.00 to RV1 for the trailer. Licensee's failures are a violation of Oregon administrative rule is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee has been substantiated.",3,,,,Financial abuse +CO15184,523542,AFH,9/2/2015,Multiple violations re: fire and life safety and refusal to correct by date listed.,3,450,,, +CO14084,523564,AFH,3/13/2014,Licensee's and caregiver's (MW) background checks both expired.,3,0,,, +CO13071,523572,AFH,6/4/2013,"On June 4, 2013, the Department received information from the local office alleging the licensee kissed Reported Victim (RV) on the lips and touched his/her breasts. The licensee did not deny the allegations but insisted that RV initiated the sexual contact. Local law enforcement is involved. UPDATE: Home closed 6/7/2013",3,0,,,Sexual abuse +CO13075,523572,AFH,6/6/2013,"On June 4, 2013, a notice of imposition of license condition was issued to the licensee based on preliminary information alleging sexual abuse of a resident. The condition imposed that the licensee may not admit or re-admit any resident to his adult foster home. The condition further imposed that the licensee may not provide any direct care or services to any of the residents at the licensee_x001A_s adult foster home. + + + +On June 6, 2013, the Department received information from the local office alleging the licensee was witnessed kissing resident #1 and stating _x001A_Better be careful, they will call it sex abuse and you will have to leave and won_x001A_t have baby (resident_x001A_s dog) since the condition was placed._x001A_ It was further alleged the licensee was observed providing direct care to resident #2. The licensee was observed _x001A_wiping resident #2_x001A_s tail bone with alcohol and applying a band aid to that area._x001A_ It was also alleged the licensee was observed applying ointment around resident #2_x001A_s mouth and eyebrows daily and has assisted resident #2 with toileting after the condition was issued prohibiting the licensee from providing any care to any resident. Since the condition was issued the licensee has been observed going into residents_x001A_ bedrooms and closing the door. + + + +Additional information received by the Department from the local office on June 6, 2013, alleged that the licensee was heard and witnessed calling resident #3 a _x001A_fuckin retard_x001A_, _x001A_fuckin idiot_x001A_, telling resident #3 that he was _x001A_sick of cleaning up her crap_x001A_ and that he would call her caseworker and have her _x001A_shipped out of here_x001A_. The licensee was also witnessed taking an anti-anxiety medication out of resident #2_x001A_s medication and ingesting it. UPDATE: Home closed on 6/7/2013",4,0,,,Neglect +AL133401A,523572,AFH,6/3/2013,"On or about June 3, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV) and Reported Victim #4 (RV4) from inappropriate sexual contact. RP was observed kissing RV2 and RV3 inappropriately on the lips. RP was ""super affecitonate"" with RV4. RP did not deny the allegations but insisted that RV's initiated the sexual contact. RP engaged in inappropriate behavior which resulted in an environment that would intimidate RV's. The licensee failed to protect RV's from inappropriate sexual contact. The failure is a violation of resident rights and constitutes abuse.",4,,,,Sexual abuse +AL133401B,523572,AFH,6/3/2013,"On or about June 3, 2013, it was alleged that Reported Perpetrator (RP) failed to properly use restraints on Reported Victim #2 (RV2). RP used a gait belt to restrain RV2 to the toilet for extended periods of time. RP instructed staff to use restraint to keep RV2 on the toilet. RP acknowledged tying the gait belt to the toilet to keep RV restrained. The licensee failed to properly use the restraint for RV2. The failure is a violation of resident rights and constitutes abuse.",3,,,,Restraints +AL133401C,523572,AFH,6/3/2013,"On or about June 3, 2013, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3) and Reported Victim #4 (RV4) from inappropriate verbal comments. RP was witnessed calling an RV a ""fucking bitch"" and ""disgusting"". RP was also witnessed calling an RV a ""little bitch ass"" and ""fucking baby"". RP threatened to contact RV1's case worker and have RV1 ""shipped out"". RP was witnessed on multiple occasions using profanity toward RV's. The licensee failed to protect RV's from inappropriate verbal comments. The failure is a violation of resident rights and constitutes abuse.",3,,,,Verbal/Mental abuse +NB121992A,523585,AFH,12/31/2012,Resident #1 was care planned needing substantial assistance with housekeeping. The investigation determined the licensee would demand Resident #1 to bring the licensee beverages and would yell at Resident #1 when Resident #1 would spill liquid or ice. Facility failed to treat Resident #1 with respect and dignity. The failure is a violation of Oregon Administrative Rule.,2,0,,, +NB121992B,523585,AFH,12/31/2012,"Resident #1 reported that the Licensee requested Resident #1 call his/her family to ask for money so licensee could pay his/her bills. On January 31, 2013, the Licensee acknowledged that he/she ""asked the family for money"" because Licensee was ""low on funds"". Licensee received $300 from Resident #1's family. Licensee failed to protect resident from financial expoitation. The failure is a violation of resident rights and constitutes financial abuse.",3,0,,,Financial abuse +AS132991,523610,AFH,4/8/2013,"On or about April 8, 2013, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RV's physician ordered that RV be turned every two hours. RV's careplan dated 1/29/2013 did not reflect the change in RV's condition. On 3/29/2013 RV was ordered stool softener 2x daily and a laxative as needed. The stool softener was not initialed on RV's Medication Administration Record dated 4/15/2013 as required. The licensee failed to properly plan care for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +AS133343,523610,AFH,5/22/2013,"On or about May 22, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate service to Reported Victim (RV). RV was scheduled for a medical appointment. RV's careplan dated 4/23/2013 indicated that RV is transferred by Medix when going to a medical appointment. On this day a car was blocking the entrance to the home and the bus driver would not back into the driveway to transfer RV. Reported Perpetrator #2 (RP2) brought RV down the driveway with RV in front of RP2. RP2's grip of the wheelchair slipped and RV fell out of the wheelchair. As a result of a the fall RV was transported to the hospital and sustained a ""closed"" fracture of a vertebra. RV was kept in the hospital for one day. The licensee failed to provide appropriate service to RV. The failure is a violation of Oregon Administrative Rule.",2,,,, +AS148985,523610,AFH,10/19/2014,"On or about October 21, 2014, Adult Protective Services received a complaint that the facility failed to provide adequate continence care. During the course of the investigation, APS substantiated that RV is incontinent of bladder and that RP went to a different doctor to have a catheter inserted into RV after RV's primary care physician informed them that the risk to the client outweighed the benefits. RP has a history of seeking catheters for residents for the caregiver's convenience. RP did not administer Miralax for bowel care but initialed the Medication Administration Record as if RP had given the Miralax to RV. The facility does not have a call light or alert system for RV to use at night to let a caregiver know about his/her toileting needs and can't yell for help. RV lays in urine all night because RP refuses to get up to help with continence, reporting that s/he ""needs"" his/her sleep. RP's failure to assist with toileting is a violation of resident rights, constitutes neglect, and is considered abuse.",2,300,,,Neglect +MV152561,523628,AFH,7/4/2014,"It was reported that on or about July 4, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). RV1 kept his/her wheelchair in the garage for going to and from appointments. At the time the garage door was being kept open for easier access in and out of the facility for Resident and staff. On July 5, 2014, RV1 mentioned to facility staff that he/she thought his/her wheelchair was missing. Licensee and RV1's family determined that the wheelchair was in fact taken from the garage of the facility. Licensee's failures are a violation of OARs, is considered neglect and constitutes abuse. Financial exploitation has been apportioned to an unknown individual in the case. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +AS132198,523698,AFH,1/19/2013,"On or about January 19, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe envrionment for Reported Victim (RV). RV was admitted the the licensee's Adult Foster Home (AFH) on 1/08/2013. It was determined that RV was a fall risk and at risk for wandering. The initial screening indicated that RV is not oriented and does have memory lapses and does not have the ability to ask for help. RV fell on 1/16/13 outside of the AFH. RV sustained bruises and scratches to h/her face as a result of the fall. On 1/17/13 RV fell in the bathroom of the AFH and did not sustain any injury. On 1/19/13 RV exited the AFH and wandered to a neighbor's house. Law enforcement was contacted and assisted RV back to the AFH. On 1/19/13 RV at approximately 8:00pm RP2 discovered RV on RV's bedroom floor. RP2 attempted to get RV up off the floor for two hours. RV refused assistance and denied that h/she was in pain. After two hours RP2 contacted RP1 and RP1 instructed RP2 to let RV remain on the floor. The following morning RP2 discovered that RV was still on the floor and RV was found to be wet with urine. RP2 assisted RV off of the floor. On 1/20/13 RV fell as RV made h/her way to the lunch table. After the fall, RV was transported to the hospital for treatment. Upon admission to the hospital it was determined that RV sustained a fracture on the left side of h/her face as a result of the falls. The licensee failed to intervene when RV's condition changed. The licensee's conduct constituted a failure to provide a safe environment. The licensee's failure is a violation of Oregon Administrative Rle and constitutes abuse. UPDATE 6/18/13: FOD sent this date. AR notified and requested that the aging process begin this date.",3,400,,,Neglect +CO14155,523698,AFH,8/8/2014,"The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on August 8, 2014, and incorporated into this notice by reference, cited the following: + + + +On August 8, 2014, the licensor made an unannounced visit to the licensee_x001A_s adult foster home (AFH). During the visit the licensor discovered Resident #1_x001A_s bedroom did not have a smoke alarm installed as required. The licensee failed to install all required smoke alarms. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. SENT THE FOD AND E-MAILED JANELLE LANDIS + + + +This conduct constituted a violation of the following licensing rules: + + + +OAR 411-050-0650(5)(h)(B) Facility and Safety Standards + +OAR 411-050-0655(6)(e) and (7)(q) Standards and Practices for Care and Services + + + +The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on August 8, 2014, and incorporated into this notice by reference, cited the following: + + + +On August 8, 2014, the licensor made an unannounced visit to the licensee_x001A_s AFH. During a review of the facility records it was discovered vaccinations for pet #1 and pet #2 were not completed as required. + + + +_x001A_ Notice of Violation and Correction issued on 7/11/2014 for failure to have required pet vaccinations + + + +_x001A_ Technical assistance provided to the licensee on 4/10/2014 for not having required pet vaccinations + + + +The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. + + + +This conduct constituted a violation of the following licensing rules: + + + +OAR 411-050-0650(2)(l) Facility and Safety Standards + +OAR 411-050-0655(6)(e) and (7)(q) Standards and Practices for Care and Services + + + +The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on August 8, 2014, and incorporated into this notice by reference, cited the following: + + + +On August 8, 2014, the licensor made an unannounced visit to the licensee_x001A_s AFH. During a review of facility records it was discovered an emergency preparedness plan was not developed and documented as required. + + + +_x001A_ Notice of Violation and Correction issued on 7/11/2014 for failure to have emergency preparedness plan developed and documented as required. + + + +_x001A_ Technical assistance provided to the licensee on 4/10/2014 for failure to have emergency preparedness plan developed and documented as required. + + + +The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. + + + +This conduct constituted a violation of the following licensing rules: + + + +OAR 411-050-0650(5)(v) Facility and Safety Standards + +OAR 411-050-0655(6)(e) and (7)(q) Standards and Practices for Care and Services + + + +The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on August 8, 2014, and incorporated into this notice by reference, cited the following: + + + +On August 8, 2014, the licensor made an unannounced visit to the licensee_x001A_s AFH. During the visit it was discovered the licensee was not operating as the primary caregiver of the home and there was not an approved resident manager working in the AFH. + + + +_x001A_ Technical assistance provided to the licensee on 4/10/2014 and 7/11/2014 informing the licensee of her responsibility to be the primary caregiver until a resident manager has been approved. + + + +The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. + + + +This conduct constituted a violation of the following licensing rules:",3,700,,, +CO14156,523698,AFH,8/13/2014,Condition issued 8/26/2014. Withdrawal issued 12/12/2014.,4,,,, +KF121839A,523701,AFH,12/10/2012,"It was reported that on or about December 10, 2012, Licensee failed to protect Resident #1 from inappropriate verbal comments. Reported perpetrator #2 (RP2) was over heard calling Resident #1 a ""piece of shit"". Both the Licensee and rp2 referred to Resident #1 as a ""piece of shit"" while being interviewed. Licensee failures are a violation of Oregon Administrative rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +KF121839B,523701,AFH,12/10/2012,"It was reported that on or about December 10, 2012, Licensee failed to protect the safety of Resident #1's property. Resident #1 moved into Licensee's facility and was there for about 4 days. When Resident #1 moved in he/she moved a large portion of his/her house hold goods. After learning of Resident #1's criminal record history Licensee and Reported perpetrator #2 (RP2) wanted Resident #1 and his/her belongings out of the facility. Licensee and RP2 dumped Resident #1's belongings off in Witness #4's (W4) front yard under a tarp. Resident #1 never lived at W4's. Resident #1's belongings sat in W4's front yard for approximately 2 weeks before he/she got his/her belongings back. Resident #1 said there were many items missing and other items had been tampered with. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO13033,523728,AFH,1/23/2013,"On January 23, 2013, the licensor conducted an unannounced visit to the licensee_x001A_s Adult Foster Home (AFH). Upon arrival Riza Robles (RR) was the only individual providing care to the residents at the AFH. It was discovered that RR did not have a cleared criminal records check as required. It was also found that RR had not completed the required caregiver preparatory training study guide. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +MM121900,523728,AFH,11/26/2012,"On or about November 26, 2012, it was alleged that Reported Perpetrator (RP) failed to assure resident rights for Reported Victim (RV). RV was admitted to RP's facility in November, 2012. RV's bedroom included a walk-in closet that RV wished to use for h/her belongings. RV was not allowed to use the closet as it was being used for storage for another resident. The closet was also being used a work office for facility staff. The closet was locked when it was not being used by facility staff. The licensee failed to assure resident rights for RV. The failure is violation of Oregon Administrative Rules.",1,0,,, +MM146161,523728,AFH,2/21/2014,"On or about February 24, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to adequately care plan for Reported Victim (RV). RV was admitted to the facility on 2/11/2014. RP1 was aware that RV had a tendency to get up during the night, RV was a fall risk, and RV had memory problems. RV had a documented fall on 2/15/2014. RV is visually impaired. RV was provided a handheld doorbell, a whistle and a baby monitor in RV's bedroom to alert RP1 for help. RP1 did not adequately care plan related to RV's fall risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO15097,523759,AFH,5/18/2015,"During the inspection, the local licensing authority found the smoke alarm did not work in a bedroom. Licensee had previously done monthly testing of smoke alarms and documented such tests. Resident manager immediately corrected. Civil penalty issued ($200 reduced to $100 for mitigating factors)",3,100,,, +HB133430,523760,AFH,6/6/2013,"On or about June 6, 2013, it was alleged that Reported Perpetrator (RP) failed to keep Reported Victim's (RV) medication record current and accurate. On 2/12/2013 Witness #1 (W1) discovered that RV's origianl medication administration record (MAR) for February 2013 was innacurate. W1 observed missing charting on RV's MAR. RP acknowledged being responsible for not charting RV's February MAR accurately. The licensee failed to keep RV's MAR current and accurate. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD121954,523767,AFH,12/5/2012,"On or about December 5, 2012, it was alleged that the Reported Perpetrator (RP) failed to protect Reported Victim (RV) from the misappropriation of RV's medications. On December 5, 2012, a medication count was conducted. It was discovered that 14 of RV's anti-anxiety pills were missing. The licensee failed to protect RV from theft of medication. The failure is a violation of resident rights and constitutes abuse.",2,0,,,Financial abuse +NB121840A,523778,AFH,12/10/2012,"It was reported that on or about December 10, 2012, Licensee failed to provide a safe environment for Resident #1. Resident #1 was hit on the head by Licensee, as a result Resident #1 had a open cut on his/her forehead above his/her left eye. Licensee's failures are a violation of Oregon Administrative Rules (OARs) and constitutes physical abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Physical Abuse +NB121840B,523778,AFH,12/10/2012,"It was reported that on or about December 10, 2012, Licensee failed to provide adequate care to Resident #2. Resident #2 was a high risk for skin breakdown but did not have open sores when he/she entered into Licensee's facility. Resident #1 did develop severe skin breakdown while at Licensee's facility as licensee failed to provide adequate care to Resident #2. Licensee's failures are a violation or Oregon Administrative Rules (OARs), is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +RD148203,523807,AFH,7/9/2014,"RV1 through 5 have lived at RP1's foster home for over a year. RP2 advised residents they could not go into the kitchen or come out of their rooms before 6:30am to 7:00am in the morning and limited resident activities. RP2 also spoke to residents in a disrespectful manner, causing fear and anxiety to RV1-RV3. The facility failed to follow resident rights, resulting in RV1-3 suffering involuntary seclusion, anxiety, and fear. This failure is a violation of resident rights, and constitutes verbal and mental abuse.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +CO13080,523818,AFH,4/17/2013,"On January 17, 2013, the local office received information that JA had an interview at the licensee_x001A_s adult foster home (AFH) for a substitute caregiver position. After a brief interview the licensee left JA in charge of the resident_x001A_s at the AFH for approximately three hours. JA was the only individual in the home providing care to the resident_x001A_s. As of 1/16/13 JA had not completed the caregiver preparatory workbook or been oriented to the AFH as required. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. On April 16, 2013, the licensee submitted her criminal records check along with fingerprints to the local office. Upon further inspection the licensor discovered that the licensee_x001A_s criminal records check expired on 3/29/2013. The licensor conducted a monitoring visit on 4/17/2013. The licensee was the only caregiver on duty. The licensee_x001A_s criminal records check was approved on 5/9/2013. The licensee failed to have a qualified caregiver on duty at all times. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,500,,, +MS146044,523818,AFH,2/10/2014,"On or about February 10, 2014, it was alleged that Reported Perpetrator (RP) failed to assure Reported Victim #1 (RV1), Reported Victim #2 (RV2) and Reported Victim #3 (RV3) resident rights. RV3's service plan dated 11/30/2013 notes that RV has no behaviors. Witness #3 (W3) worked at RP's for a weekend. During the weekend RV3 got upset at W3 and was cursing and yelling. W3 observed RV3 yell and direct curse words toward RV1 and RV2. Witness #2 confirmed that RV3 does have behaviors and can be verbally aggressive and will slam doors and use bad language and be inappropriate with others. RP stated that RV3 does not have behaviors and was not aware that RV3 was a developmentally disabled resident. The licensee failed to assure RV's rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14132,523818,AFH,7/16/2014,Suspension of license hand delivered 7/17/2014,4,,,,Neglect +MS147777,523818,AFH,7/17/2014,"On or about July 17, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate staffing for Reported Victim #1 (RV1), Reported Victim #2 (RV2) and Reported Victim #3 (RV3). During the night of July 16, 2014, RP left the facility unattended. During the night RV1 was awoken by RV2 calling for help. RV1 attempted to locate RP, but RP's room was locked and RP's car was gone. RV1 attempted to contact 911 but the phone was not operable. RV1 than went outside and began yelling for help. A passerby stopped as a result of RV's yelling and contacted 911. Law enforcement was dispatched to the facility. RV2 was found to be in distress and was transported to the hospital for treatment. RP was subsequently contacted at Witness #5's (W5) house. RP arrived back at the facility where RP acknowledged that she had left the RV's unattended for several hours and stated that she had done this before on one other occasion.",3,,,,Neglect +BO146535A,523841,AFH,3/23/2014,"On or about March 25, 2014, it was alleged that Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) from inappropriate physical contact. RV1 stated that he/she was touched inappropriately by RP2, and stated that he/she would not say that in court because he/she wanted to stay in the adult foster home (AFH). RV1 stated that RP2 put h/h penis in RV1's face. RV1 continued to say that ""I know they don't believe me and I don't want to get kicked out."" RV2 stated that RV2 was in bed trying to sleep and RP2 came into RV2's bedroom multiple times and held RV2's arms against the bed and talked about RV1 needing to go to sleep. RV2 noted that RP2 was going back and forth between RV2 and RV1's bedroom. RV2 believed that RP2 was under the influence of some kind. RV2 then got up from bed and went into RV1's bedroom and observed RP2 falling into a shelf. RV1 disclosed to RV2 that while RV1 was sitting on the toilet, RP2 came in and put his/her penis in RV1's mouth. RV1 continued to say that RP2 followed RV1 and straddled RV1 on the bed and held RV1's arms down on the bed and RV1 struggled to push RP2 off of him/her which is how RP2 fell into the shelf. RV2 stated this took place during a Saturday night going into Sunday morning. Witness #1 (W1) stated that RV1 disclosed to him/her that RP2 had come into the bathroom and while RV1 was sitting on the toilet RP2 put his/her penis into RV1's mouth. RP2 then followed RV1 into bed and straddled RV1 while holding RV1's arms down against the bed and RV1 struggled to get RP2 off of him/her. RP1 stated that RV1 likes to hug and touch RP2 whenever RP1 is not around. RP1 continued to say that RV1 tells stories all the time that are not true. RP1 stated that RV2 does tell the truth and RP1 trusts what RV2 says. RP2 stated that he/she was not drinking or doing anything illegal. RP2 stated that RP2 never went into RV1's room that night, and that he/she only stood in the doorway. The licensee failed to protect RV1 and RV2 from inappropriate physical contact. The failure is a violation of resident rights and constitutes abuse.",4,,Not Substantiated,Substantiated,Sexual abuse +ES132449,523870,AFH,2/15/2013,"Resident #1 admitted to Licensee's adult foster home on or about January 27, 2013. Licensee failed to obtain written physician's orders for Resident #1's anti-anxiety medication prior to Resident #1's admission. Resident #1's Medication Administration Record (MAR) for February 2013 indicates Resident #1 was administered Medication #1 as follows: a total of three milligrams on February 2, three milligrams on February 5, two milligrams on February 7, three milligrams on February 10, one milligram on February 12 and three milligrams on February 14, 2013. Upon review of the physician's order, Resident #1 was to receive 1.5 milligrams on each of those days. Facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rule.",2,0,,, +ES132330,523870,AFH,2/1/2013,"It was determined that on or about February 1, 2013, Resident #1 (RV1) was left in the adult foster home (AFH) without staff on duty. Licensee acknowledged that he/she was away from the AFH between approximately 3:00pm and 5:30pm that day. Licensee failed to ensure a qualified caregiver was present and available in the AFH at all times, twenty-four hours per day, seven days per week. Licensee's failure is a violation of Oregon Administrative Rules.",3,0,,, +RB132441,523884,AFH,2/8/2013,"It was reported that on or about February 8, 2013, Licensee failed to provide a secure medication system. On February 3, 2013, one of Resident #1's narcotic medication was found to be missing. Licensee was unable to determine what happened to Resident #1's single tab of narcotic medication. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +RB148013,523884,AFH,7/20/2014,"On or around July 31, 2014, Adult Protective Services (APS) received an allegation that the facility failed to protect the RV from verbal and emotional distress. During the course of the investigation, APS determined that Resident 1 and Reported Perpetrator 2 (RP2) did not get along and that the facility was aware of this situation. RP2 would raise his/her voice and yell at Resident 1, which the facility was aware of as well. The facility would have both Resident 1 and RP2 sit together at a table and confront each other on issues so that the facility could determine who was telling the truth, even though it could cause Resident 1 emotional distress. The facility was aware that RP2 has behavioral issues causing RP2 to yell at residents but stated that a behavioral specialist comes to the AFH to work with RP2 on his/her behavioral issues. The facility failed to protect Resident 1 from mental or emotional distress. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MV150274,523904,AFH,2/12/2015,"On or about February 17, 2015, it was alleged that Reported Perpetrator (RP) failed to potect Reported Victim (RV) from financial exploitation. RV has multiple medical appointments which he/she cannot attend alone due to his/her condition. When RV first arrived at the facility Witness #1 (W1) was privately paying a driver to transport and assist RV at the medical appointments. Shortly after that individual quit RP hired a driver to transport RV and assist with care using RV's funds. During one month the bill totaled $700.00. The licensee failed to protect RV from financial exploitation. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +MV164385,523904,AFH,1/18/2016,"RV has doctor's orders for his/her blood sugar to be checked four times daily. RV does his/her own blood sugar checks, but four hour checks are not being done per doctor order. RV has another medication to be given after non-medication interventions, but facility records do not indicate non-medication interventions are occuring; and the medication is not being recorded on the MAR",2,,,, +HM132391A,523909,AFH,1/7/2013,"It was reported that on or about January 7, 2013, Licensee failed to protect Resident #1 from inappropriate verbal comments. Reported Perpetrator #2 (RP2) yells at Resident #2 and is verbally abusive to Resident #1, RP2 has called Resident #1 a bitch and a bastard. Licensee's failures are violation of Oregon Administrative Rules and constitute verbal abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,Substantiated,Substantiated,Verbal/Mental abuse +ES150151,523999,AFH,1/1/2013,"On or about 2/5/15, APS received a complaint that the facility failed to protect residents from wrongful use of restraints. During the course of the investigation, APS determined that half rails were used on the beds of Residents #1, 2, and 3. RP1 failed to provide the required documentation in order to use bedrails, including the assessment, the need for and ongoing assessment of use, verification the residents requested bedrail use, and doctor orders for use of rails for residents #2 and 3. Facility's failure to obtain and maintain documentation required for the use of bedrails is a violation of Oregon Administrative Rule. Facility's improper use of restraints constitutes abuse.",2,,,,Restraints +ES164503,523999,AFH,1/28/2016,"RV1 was prescribed a breathing medication on January 27, 2016. RV1 was administered three times the prescribed medication amount of his/her breathing medication. The facility falsified RV1's Medication Administration Record (MAR) while Department staff interviewed RV1 at the adult foster home. During the investigation, it was self-reported that RV1 was administered two times the prescribed amount of a mood medication from January 12, 2016 until February 8, 2016. The facility failed to administer RV1's medicaion as ordered placing RV1 at risk of harm.",2,300,,, +CO16076,523999,AFH,2/24/2016,Licensee failed to provide a safe medication administration system and three violations were written for the following: Medicaition Administration Records did nt match the physician orders for three residents. Medications listed on the MARs did not required physician orders for two resiidents. The advance set-ups were not in compliance with OARs for four residents. Request for CP santion granted for $150.00,3,150,,, +CO14182,524000,AFH,9/17/2014,FOP sent 12/8/14,3,250,,, +MS134490,524006,AFH,9/19/2013,"On or about September 20, 2013, it was alleged that Reported Perpetrator (RP) failed to administer medication as ordered to Reported Victim (RV). RV is ordered to receive a blood thinning medication. RV's blood thinning medication dosage is adjusted by RV's doctor based on RV's INR levels. During the period of 9/1/13-9/18/13 RV was to receive the medication as follows 1st-4th (3mg), 5th (4.5mg), 6th (3mg), 7th (3mg), 8th (4.5mg), 9th (3mg), 10th (4.5mg), 11th (3mg), 12th (4.5mg), 13th (3mg), 14th (4.5mg), 15th (4.5mg), 16th (3mg), 17th (4.5mg), 18th (3mg). RV's medication administration record for September 2013 does not reflect the correct dosage per RV's physician order. The licensee failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14053,524044,AFH,3/11/2014,"On March 11, 2014, a monitoring visit was conducted at the licensee_x001A_s adult foster home (AFH). Shortly after the arrival, the licensor observed the licensee attempting to initial the medication administration records (MAR_x001A_s) for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) dating back to February 27th, 2014. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,200,,, +CO16054,524052,AFH,3/7/2016,"The LLA conducted an unannounced monitoring visit and discovered an unqualified caregiver in the home, alone. Unqualified caregiver did not have an approved background check, nor did she have a certificate for completing the caregiver prep workbook. Licensee has previously had unqualified caregivers in 10/13.",3,300,,, +CO13118,524057,AFH,10/2/2013,"Upon renewal insoection completed on October 1, 2013, it was discovered Licensee had unqualified care A.F. working in his/her Adult Foster Home (AFH) with an expired background check. During the inspection caregiver A.F. arrived at Licensee's AFH, picked RV1 and transported RV1 to his/her appointment with no other qualified caregiver present. Licensee;s failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated. 12/5/14 FOP",3,250,,, +CO15196,524057,AFH,9/21/2015,Failure to update Care Plans for three residents. Failure to document weekly Progress notes for three residents. Noncompliance regarding Medication Administration Record. Failure to have all current prescribed medications available in the Adult Foster Home for administration.,3,800,,, +HB134708,524092,AFH,10/11/2013,"On or about October 14, 2013, it was alleged that Reported Perpetrator (RP) failed to follow Reported Victim's (RV) care plan. RV's care plan dated 7/30/2013 notes that RV has a ""fall prevention plan"", is a fall risk and requires full assistance with toileting. RV was transported to the restroom by Witness #2 (W2) and left alone. As a result RV bumped his/her head on a board on the bathroom wall. RV stated that the bump resulted in mild pain. The licensee failed to follow RV's care plan. The failure is a violation of resident rights and constitutes abuse.",2,,,,Neglect +MV146297A,524107,AFH,2/12/2014,"It was reported that on or about February 12, 2014, Licensee failed to provide a safe medication system. Licensee failed to follow physcian's orderd for one of Resident #1's (RV1) prescribed medications. Licensee failures is a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO14218,524107,AFH,10/13/2014,Civil penalty #AFHCP14-154 imposed due to multiple medication violations and a dismantled smoke alarm.,3,400,,, +MV149501,524107,AFH,12/8/2014,"On or about 12/8/14, Adult Protective Services (APS) received a complaint that the facility failed to protect RV from theft. During the course of the investigation, APS substantiated the following: RV was admitted to the AFH on 12/16/13 and was Medicaid eligible at that time. RP1 expressed concern about the pay rate to care for RV to RV's case manager (CM) prior to RV's admission to the home and contacted the CM about Medicaid status and payments during RV's stay at the AFH. Both RP1 and RP2 knew that RV was a Medicaid client, not a private pay client and RP2 signed SDS-512 documents on 1/1/14, 1/6/14, and 7/3/14 agreeing to accept the listed monthly Medicaid payments as payment-in-full in return for RV's care. RP1 stated during the investigation that RP1 had never seen a 512 document and did not know what the 512 document was. On 4/6/14, RP1 presented a private pay contract to W1 for RV's care, requiring W1 to pay more than the monthly Medicaid payments listed in the SDS-512. On 8/21/14, RP2 presented a private pay contract to W1 for RV's care, requiring W1 to pay more than the monthly Medicaid payments listed in the SDS-512. RP1 accepted payments from W1 in the amounts specified in the private pay contracts. Prior to admission, W1 told RP1, and RP1 understood that RV was not to access pornography via the AFH television. RP1 billed and accepted payment from W1 for pay per view pornography accessed by RV while staying at RP1's AFH. The facility failed to protect the resident from financial exploitation. This failure is a violation of resident rights and constitutes financial abuse.",3,400,,,Financial abuse +AS147382,524121,AFH,6/5/2014,"Resident #1 (RV) admitted to licensee_x001A_s adult foster home in August 2013. An assessment conducted by the department on August 7, 2013 indicated that RV was fully dependent in nearly all Activities of Daily Living (ADLs), including dental care. RV_x001A_s care plan also dated August 7, 2013 documented that RV had a partial plate in his/her mouth that needed to be removed at night. Witness #1 (W1) stated that the facility realized soon after RV moved in that RV would bite the toothbrush and swallow the toothpaste when dental care was attempted. + + + +On or about June 5, 2014, RV visited a healthcare professional. It was determined that the plate hadn_x001A_t been cleaned for quite some time as the gum matter had started to grow over his/her plate. Witness #2 (W2) reported that RV_x001A_s dentist was concerned about the possible build up of bacteria and risk of infection as the partial had not been removed and cleaned regularly. W1 acknowledged that neither RV_x001A_s physician nor dentist had been contacted when the AFH realized that the provision of dental care to RV was difficult. + + + +The investigation concluded that Licensee failed to follow RV_x001A_s care plan and failed to notify RV_x001A_s healthcare professional(s) when there was a change in RV_x001A_s health status. Licensee_x001A_s failures are violations of resident rights, are considered neglect and constitute abuse. FOP sent out 12/8/04",3,400,,,Neglect +BO135530,524143,AFH,12/21/2013,"It was reported that on or about December 21, 2013, Licensee failed to provide a system that prevents theft or misuse of Resident #1's medication. On December 21, 2013, it was discovered that a bottle of Resident #1's prescribed medication had been emptied and replaced with an over the counter medication. Licensee's failures are a violation of Oregon Administrative Rules. The theft of Resident #1's medication is considered financial exploitation and constitutes abuse. Abuse has been apportioned to an unidentified individual in this case.",3,,Not Substantiated,Substantiated,Financial abuse +CO14158,524143,AFH,5/14/2014,Unqualified caregiver left alone with residents.,2,250,,, +BO147103,524143,AFH,4/21/2014,"It was reported that on or about April 21, 2014, Licensee failed to provide a safe environment for Resident Victim #1 (RV1). Licensee failed to provide RV1 with appropriate care and services reulting in RV1 sustaining multiple pressure wound sores. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules is considered neglect and constitutes abuse.",3,400,,,Neglect +BO146765,524143,AFH,5/14/2014,"It was reported that on or about May 15, 2014, Licensee failed to provide adequate care for Resident #1 (RV1). Licensee failed to ensure RV1 had an appropriate bed for his/her needs resulting in RV1 sleeping in a recliner without appropriate bedding. Licensee failed to ensure appropriate staffing for transfering RV1 when needed. Licensee's failures are a violation of Oregon Administrative Rules is considered neglect and constitutes abuse.",2,,,,Neglect +RD149507A,524143,AFH,12/3/2014,"On or about December 4, 2014, APS received a complaint that facility failed to provide medication as ordered to RV1 and RV2. During the course of the investigation, APS substantiated that RV1's 12/3/14 MAR (medication administration record) did not show RV1's 2:00pm dose of muscle relaxant was administered. Pill count shows one extra pill than should be present if medication had been given and not documented. The 12/3/14 MAR for RV2 indicates RP2 gave RV2 a whole tablet at 12:00 pm instead of the ordered half-tablet of anti-anxiety medication at 2:00pm. RP2 admitted to giving RV2 a whole tablet but thought he/she documented the wrong administration time on the document. RP2's failure to follow doctor orders is a violation of resident rights, is considered neglect, and constitutes abuse. Licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rule.",3,,Not Substantiated,Substantiated,Neglect +RD149507B,524143,AFH,12/3/2014,"On or about December 4, 2014, APS received a complaint that the facility failed to provide appropriate care to RV2. During the course of that investigation, APS substantiated that RV2 uses a catheter bag which must be emptied at regular intervals, which is noted in RV2's care plan. On 12/3/14, RP2 worked an eight hour shift and did not empty RV2's catheter bag during that time, although RV2 had requested it to be emptied after it became full and RP2 had stated that he/she would come and do so. RV2 had some discomfort due to his/her catheter bag not being emptied as requested. RP2's failure to follow the care plan and empty RV2's catheter bag is a violation of resident rights, is considered neglect and constitutes abuse. Facility's failure to provide a safe environment is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Neglect +RD135208,524144,AFH,10/24/2013,"On or about October 24, 2013, it was alleged that Reported Perpetrator (RP) failed to assure timely medical treatment for Reported Victim (RV). RV fell outside of the adult foster home (AFH) while RP was conducting a fire drill. Witness #1 (W1) and Witness #2 (W2) assisted RV back up. RV did not complain of pain and there were not visible injuries. The following day RV began to complain of leg pain. RP and Witness #3 (W3) decided to wait a few days to see if RV would get better. RV continued to complain of pain for the next several days. RV was not scheduled to see a physician until 10/30/14. It was discovered that RV sustained a fractured hip due to the fall. RV was transported to the hospital where he/she required surgery. RV's progress notes dated 10/30/13 states ""RV in a lot of pain last few days- Says it is his/her knees and can't walk; Sits in walker and pushes self around and also had two incontinent accidents which is not usual. Refusing pain pills or seeing a doctor."" The licensee failed to assure timely medical treatment for RV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD147647,524144,AFH,5/27/2014,"On or about May 28, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe medication administration system for Reported Victim (RV). Between January and May of 2014 Complainant #2 (C2) delievered RV's pain medication to RP's adult foster home. RV's prescription bottles used for refills stated 5/325mg tablets to be given as 1/2 to 1 pill by mouth every 8 hours. RV's medication administration record stated 5/325mg tablets to be given as 1-2 tablets by mouth every six hours. The licensee failed to provide a safe medication administration system for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB153442B,524168,AFH,11/5/2015,RV1 was a resident of Licensee's adult foster home. RV1 was prescribed medications to control his/her bowl movements. RV1's bowel control medications were changed frequently. Bowel medication A was ordered to be given once a day at bedtime from 8/7/15 to 10/8/15 but RV1 was administered Medication A twice per day instead. The facility failed to follow physician orders.,2,,,, +HB164135,524168,AFH,12/4/2015,"It was reported that on or about December 4, 2015, Licensee failed to provide a safe environment and appropriate supervision for Resident #1 resulting in Resident #1 sustaining a fall. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +MS135124A,524226,AFH,11/19/2013,"It was reported that on or about November 19, 2013, Licensee failed to provide a safe medication administration system. Reported Perpetrator #2 (RP2) placed Resident #1's and Resident #2's medication in separate cups and placed them next to one another on the table. Resident #1 picked up a cup and took the wrong medications. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MF149429,524226,AFH,12/3/2014,"It was reported that on or about December 3, 2014, Licensee failed to provide a safe medication administration system. Licensee failed to follow physician's orders for Resident #1's (RV1) prescribed medications, failed to acquire new ordered medications, administered medication that were discontinued by RV1's physician and failed to properly document on RV1's medication administration record. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the License was substantiated.",2,,,,Neglect +MF151431,524226,AFH,6/2/2015,"RV1 moved into the adult foster home in April 2015. According to witness interviews and facility progress notes RP2 is abrupt with RV1 at times. RP2 gets irritated and angry with RV1. RV1 had concerns regarding RP2 and his/her care and expressed those concerns to RP1. RP1 spoke with RP2 and addressed RV1's concerns. RP2 confronted RV1 about him/her discussing his/her concerns with RP1 first before speaking with RP2. RV1 felt ""jumped and yelled"" at by RP2 resulting in RV1 not feeling safe and afraid to talk to RP2. As a result, RV1 experienced fear, increased anxiety and an increase in medication.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +CO16066,524226,AFH,3/16/2016,,4,,,,Neglect +MV134756B,524271,AFH,10/17/2013,"On October 17, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) and Reported Victim #2 (RV2) inappropriate verbal comments. Reported Perpetrator #2 (RP2) and RV2 were having a conversation and RP2 started a discussion about sexual equality. RP2 discussed sexual experiences that RP2 had in h/h past. As a result RV2 felt uncomfortable and asked that RP2 not discuss it again. RP2 acknowledged what he/she said was inappropriate. The licensee failed to protect RV2 from loss of dignity. The failure is a violation of Oregon Administrative Rule.",2,,,, +MV134756A,524271,AFH,10/17/2013,"On or about October 17, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to assure Reported Victim #1's (RV1) resident rights. RV1 had a medical procedure on h/h right wrist on 10/11/13 which made it sensitive. Reported Perpetrator #2 (RP2) brought RV1 a bottle as RV1 requested. RV1 dropped an item and RP2 was on the floor searching for it. While RP2 was on the floor RV1 realized that he/she could not hold onto the bottle that RP2 had given h/h and asked RP2 for help. RP2 got up and ""yanked"" the bottle from RV1. RV1 did not sustain any injury but complained of pain to RV1's wrist. The licensee failed to assure RV1's resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV148551,524271,AFH,9/14/2014,"On or around September 15, 2014, Adult Protective Services (""APS"") received a complaint alleging facility failed to properly manage RV's medications. During the course of the investigation, APS determined that RV moved into the home and had medication refilled and brought to the facility. Medication refill was for 90 pills. Facility locked up the medications and documented administering 3 pills per day from 8/26/14 through 9/12/14. Facility can account for 66 pills. On 9/12/14, RV discharged from the home and was given the remaining 2 pills; leaving 22 pills missing/unaccounted for. The facility failed to provide a system that prevents theft or misuse of RV's medications, resulting in loss of resident_x001A_s medication. This failure is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +MV148019B,524271,AFH,8/1/2014,"On or about August 6, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to administer medication to Reported Victim (RV) as ordered. RV was prescribed Adderall 30mg to be taken three times daily. The 30mg pills were cut in half to 15mg. The pills were then cut in half again to 7.5mg. The Adderall was not dispensed as prescribed by RV's physician. RV's medication administration record (MAR) notes that 30mg Adderall was dispensed daily with no documentation demonstrating the 30mg pill was cut into 7.5mg. The licensee failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV148019A,524271,AFH,8/1/2014,"On or about August 6, 2014, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from inappropriate verbal comments. Visitors from a mentor association arrived at the adult foster home (AFH) unannounced to pick up RV. RV was not present at the AFH. When RV arrived home Reported Perpetrator #2 (RP2) yelled and screamed at RV stating that the visitors were not allowed unannounced. As a result RV felt embarrassed and locked him/her self into his/her bedroom. RP2 acknowledged yelling at RV.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MV152432,524271,AFH,8/11/2015,"On or about August 11, 2015, Adult Protective Services (""APS"") received a complaint that the facility failed to provide the proper care to meet RV's needs. During the course of the investigation, APS determined that RV states that he/she is diabetic and needs a special diet. RV's care plan documents that he/she is diabetic and that diabetes is controlled through diet, including a specific amount of servings of fruits and vegetables. RV has doctor orders to check blood sugar twice daily, diagnosis diabetes mellitus and the August medication administration records (MAR) lists lance, test strip, and glucose for blood sugar. Facility caregivers check RV's blood sugar twice daily. The facility does not offer a diabetic diet and both RP2 and W1 state that they were unaware RV had a diagnosis of diabetes. RP2's failure to follow RV's care plan is also a failure to follow resident rights, is considered neglect, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MV152192A,524271,AFH,7/20/2015,"On or about July 21, 2015, Adult Protective Services (APS) determined the following: Licensee (RP1) is responsible for completing and signing resident care plans. Licensee did not complete or sign RV's care plan. The portion of RV's care plan which is complete notes that RV has memory issues, is full assist in cognition/behavior, and that caregivers are to keep track of appointments and get RV there on time. RV missed several appointments due to either not being reminded that the appointments were scheduled or not having medical transportation scheduled correctly. Licensee's failure to complete RV's care plan is a violation of Oregon Administrative Rule (OAR). Licensee's failure to arrange for or provide appropriate transportation for RV to get to medical and dental appointments is a violation of OAR and resident rights, is considered neglect, and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MV152192B,524271,AFH,7/20/2015,"On or about July 21, 2015, Adult Protective Services (APS) received a complaint that the facility failed to protect RV from harassment. During the course of the investigation, APS determined that RP1 accused RV of stealing and had RV empty out RV's backpack in front of other residents and staff, which caused RV to feel humilated. RP2 speaks to RV in an angry, raised voice, in close physical proximity to RV. RP1's actions are a violation of resident rights, and is considered emotional abuse. RP2's actions are a violation of resident rights and is considered verbal abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +MV151649A,524271,AFH,6/10/2015,"On or about June 18, 2015, APS received a complaint that the facility failed to maintain a safe medication system. During the course of the investigation, APS substantiated the following: On June 17, 2015 RV1 had an appointment and was sent with 3 medications to self-administer while RV1 was out of the AFH. The medication, which included a PRN, was placed in old bottles rather than a labeled advanced set up container. RV1 did not have a doctor's order to self-administer his/her own medications. In addition, RV1 was given a PRN (as needed) nausea medication at 11:00 am and 2:00 pm on June 17, 2015, which was too soon according to physician orders. During RV1's medical appointment on June 17, 2015, he/she became dizzy and ill and had to retun to the facility. The facility failed to administer medications according to physician orders and failed to provide a safe and secure environment. The facility's failures are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Neglect +MV151649B,524271,AFH,6/10/2015,"On or about June 18, 2015, APS received a complaint that the facility failed to follow RV1's care plan, resulting in injury. During the course of the investigation, APS substantiated that RV1's care plan indicates that RV is at risk for falling so a same sex caregiver must assist RV out of the shower. No same sex caregiver was working and available on June 10, 2015. RP2 administered RV1's sleeping pill and then directed RV1 to take a shower, even though RV1 expressed discomfort with showering after taking the sleeping pill and not having a caregiver in the bathroom. RP2 stated that s/he would stand outside the door but did not do so. Instead, RP2 sat down in the living room and fell asleep. RV1 fell getting out of the shower and hit his/her head, which resulted in him/her passing out. RV1 awoke and attempted to alert RP2 by screaming and calling on the phone but was unsuccessful. RV1 was taken to the hospital and complained of pain in his/her shoulder and head. RP2 failed to follow RV1's care plan resulting in harm to RV1. This failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,700,Substantiated,Substantiated,Neglect +MV153271A,524271,AFH,10/26/2015,"RV1 was a resident of Licensee's adult foster home. RV1 was prescribed medication #1, which RP2 filled on October 23, 2015. On October 26, 2015 the prescription bottle for medication #1 was observed to be empty. RP1 and RP2 were unable to determine where the missing medication #1 pills went. When reviewed, RV1's medication administration record (MAR) indicated that medication #1 was administered four times with only two times corresponding with RV1's physician's orders. The facility failed to follow RV1's physician orders regarding medication #1 and failed to provide a safe and secure medication administration system. The facility's failures are violations of the Oregon Administrative Rules (OAR's).",2,,,, +ES134376A,524302,AFH,9/7/2013,"It was reported that on or about September 7, 2013, Licensee failed to protect resident's form neglect of care. Resident #2 (RV2) stated Reported Perpetrator #2 (RP2) gave him/her a note stating RP2 was leaving the facility and leaving his/her shift to go to the hospital as he/she was having chest pains. RP2 left his/her shift and did not inform the off duty care giver (W1) prior to leaving the resident unattended with no other caregiver present to provide care for all residents. RP2s failures are a considered neglect and constitutes abuse.",2,,Not Substantiated,Not Substantiated,Neglect +ES150069A,524302,AFH,12/1/2014,It was reported RP2 had a loud voice and raised his/her voice at residents and yelled at RV1. RP2 did not remember yelling at anyone and stated it was possible that he/she did without knowing it. The facility had a Behavior Specialist working with RP2 regarding how to interact with RV1. The facility failed to protect RV1 from being treated with dignity and respect. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated, +GP132317A,524351,AFH,2/4/2013,"It was reported that on or about February 4, 2013, Licensee failed to provide a safe environment for Resident #1. Resident #1 is on oxygen at night and as needed during the day. Licensee admitted to smoking in the home while Resident #1 is on oxygen. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO13025,524360,AFH,3/13/2013,"It was reported that on or about March 13, 2013, Licensee failed to provide a safe environment for Resident #1. On March 13, 2013, the Department received preliminary information from the Local Office that indicated the Licensee had been a victim of domestic violence. On March 13, 2013, Licensee contacted local law enforcement stating that she had returned home and John Konstantakis (John) was cooking dinner. Licensee asked John to leave the facility and he left. Approximately ten minutes later John returned and began pounding on the door and ringing the doorbell. Licensee opened the door to tell John to be quite as Resident #1 was sleeping. John then pushed his way through the door and hit Licensee in the face and said _x001A_I_x001A_m sick of you changing your mind and telling me what I can and can_x001A_t do_x001A_. Licensee told police that since the break-up three weeks ago John_x001A_s behavior has gotten more aggressive and obsessive. Licensee told law enforcement that John stays on the opposite side of the property and has had ongoing harassment issues with John.",3,0,,, +AL135034,524401,AFH,9/25/2013,"The licensee (RP) was Resident #1 (RV) primary caregiver for approximately three years. On or about September 23, 2013, RP was notified by his/her banking institute that RV's account had been overdrawn. Witness #1 (W1) and RV reviewed his/her bank statements from July 2013 to September 2013 and RV noted several unauthorized withdrawals were made. On September 24, 2013, RP gave RV back RV's debit card, $120.00 and a signed handwritten letter from RP stating that RP had stolen $120.00 from RV. Adult protective services filed a report with law enforcement on September 25, 2013. The law enforcement report dated September 25, 2013, stated that after further review of RV's bank statements RP made unauthorized withdrawals from 8/4/2012 to 12/31/2012 totaling $3344.90 and from 1/3/2013 to 9/24/2013 totaling $2419.14. It was determined that RP had fraudulently used RV's debit card to withdrawal a total of $5764.04. RP acknowledged to law enforcement that RP had been intentionally stealing RV's money for RP's own benefit without RV's permission with intent to injure or defraud RV for approximately a year. The licensee failed to protect RV from financial exploitation. The licensee's failure is a violation of resident rights and constitutes abuse.",4,,,,Financial abuse +CO14019,524401,AFH,9/25/2013,"The licensee (RP) was Resident #1_x001A_s (RV) primary caregiver for approximately three years. On or about September 23, 2013, RP was notified by his/her banking institute that RV_x001A_s account had been overdrawn. Witness #1 (W1) and RV reviewed his/her bank statements from July 2013 to September 2013 and RV noted several unauthorized withdrawals were made. On September 24, 2013, RP gave RV_x001A_s debit card back to RV along with $120.00 and a signed handwritten letter from RP stating that RP had stolen $120.00 from RV. + + + +Adult protective services filed a report with law enforcement on September 25, 2013. The law enforcement report dated September 25, 2013, documented that after further review of RV_x001A_s bank statements RP made unauthorized withdrawals from 8/4/2012 to 12/31/2012 totaling $3,344.90 and from 1/3/2013 to 9/24/2013 totaling $2,419.14. It was determined that RP had fraudulently used RV_x001A_s debit card to withdrawal a total of $5,764.04. RP acknowledged to law enforcement that RP had been intentionally stealing RV_x001A_s money for RP_x001A_s own benefit without RV_x001A_s permission with intent to injure or defraud RV for approximately one year. The licensee failed to protect RV from financial exploitation. The licensee_x001A_s failure is a violation of resident rights and constitutes abuse.",4,,,,Financial abuse +CO15027,524448,AFH,2/2/2015,Licensee had removed the battery in the smoke alarm located at the top of the stairway. Licensee's failure to maintain functioning smoke alarms is a violation of AFH OARs.,3,250,,, +CO14046,524468,AFH,2/24/2014,UPDATE: FOD complete 6/8/14 and e-mail sent to AR requesting the AGING PROCESS begin.,3,750,,, +MV134198,524481,AFH,8/19/2013,"It was reported that on or aboyt August 19, 2013, Licensee failed to provide appropriate care for Resident #1 (RV1). Licensee failed to ensure a qualified caregiver was present 24 hours per day. Licensee's failures are a violation of oregon administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO15235,524484,AFH,11/16/2015,For failure to install required smoke detector in living room and top of the stairway.,3,500,,, +CO14075,524500,AFH,4/18/2014,Licensee with expired background check and caregiver #1 had not completed preparatory workbook or background check.,3,500,,, +CO14166,524500,AFH,9/2/2014,"Based on preliminary information received from local office, caregiver/significant other of licensee convinced RV to expose breasts in exchange for gifts. RP also took RV to Bandon twice for overnight stay in motel and purchased RV's medical marijuana and gave candy and clothes in exchange for oral sex or attempts of oral sex. After APS investigation started, RV made plans to commit suicide due to emotional difficulties she felt she had caused licensee and licensee's family.",4,0,,,Sexual abuse +RS148295A,524500,AFH,8/20/2014,"Adult Protective Services (APS) received an allegation and, in the course of the investigation, substantiated the following occurred during a period of approximately one month or so during the summer of 2014: RV1's care plan did not indicate s/he needed sponge baths but RP2 gave RV1 sponge baths on multiple occasions. RP2 asked RV1 to expose him/herself to RP2 after hearing that RV1 had exposed RV1's upper chest area to another resident. RP2 then asked RV1 to expose his/her upper chest area on multiple occasions, which RV1 did. RP2 discussed becoming more intimate with RV1, who was against the idea at first. RP2 took RV1 to Bandon, Oregon on two occasions and convinced RV1 to stay in a hotel with RP2. RP2 purchased medical marijuana, sex toys, and gave money to RV1 in exchange for sex. RP2 talked RV1 into performing oral sex on RP2 and told RV1 not to tell anyone about it, which RV1 agreed to. Due to feeling bad about what happened between RV1 and RP2, RV1 made plans to commit suicide but ultimately did not complete the plan. RP2 denied any sexual relations when originally questioned by APS but then admitted to it and stated that he/she felt ""set up"" by RV1. RV2's care plan did not indicate s/he needed sponge baths but RP2 gave RV2 sponge baths on multiple occasions. RV2 states that RP2 and RV2 had sexual intercourse and oral sex several times; when RP1 would leave the home, RP2 would then ask RV2 for sexual favors. RP2 denied sexual relations with RV2 when first questioned by APS and then stated that ""everything that happened with everyone was consensual"". RP2 has been evaluated to have an IQ 69 or lower and diagnoses of mental deficiency and a genetic disorder that causes social vulnerability. RV2 is now scared that people will not like him/her or want to be with him/her. The facility failed to provide a safe environment for Residents 1 and 2. The failure is a violation of resident rights and constitutes sexual abuse.",4,,Not Substantiated,Substantiated,Sexual abuse +RS148295B,524500,AFH,8/20/2014,"RV2 moved out of this facility on or about 8/27/14, and was missing 30 plus narcotic pills and $100.00. RV2 had an order for narcotics and had no order to discontinue this medication. The facility confirmed that there was no order to discontinue the narcotics but stated facility destroyed the pills because they made RV2 sick. The facility did not document disposal of RV2's medication in the resident's record, nor did the facility have the disposal of the controlled substance witnessed by a caregiver who is 18 years of age or older. The facility held RV2's bank card and would take RV2 to the bank to withdraw money for the resident's purchases. Facility confirmed that the facility did not give cash to RV2 and stated that the facility kept receipts of said purchases. Facility could produce no separate account record maintained under RV2's name. RV2 states s/he never saw the money or the card and felt angry because s/he had no money to purchase things at his/her discretion. Facility failed to protect the resident from financial exploitation. This failure is a violation of resident's rights and constitutes financial abuse.",3,800,,,Financial abuse +RS148295C,524500,AFH,8/20/2014,"On or about September 2, 2014, Licensee decided to voluntarily surrender the facility license and was counseled to make sure RV3 was not residing in the AFH alone. Licensee and caregiver moved out of the adult foster home by September 4, 2014, and into a recreational vehicle located several miles from the facility. On September 4, 2014, Licensee told the Adult Protective Service (APS) investigator that RV3 had moved out of the facility. APS checked RV3's bedroom and found RV3's personal possessions still in the room. APS asked licensee about the reason that RV3's personal possessions were still in the room and licensee ""did not know"" the reason. Licensee then admitted that RV3 still lived in the home and that other people living on the same property, in separate buildings, assisted RV3. RV3 had lived alone in the AFH for several days. Licensee left the facility prior to RV3 finding placement and failed to assure that a qualified caregiver was present to meet resident's care needs. Licensee's failure constitutes abandonment and is considered abuse.",3,,,,Abandonment +CO15064,524502,AFH,3/27/2015,Neither provider nor co-provider had an approved criminal background check on date of inspection 3/18/15. Provider's bcu expired 2/5/15 and co-provider's expired 3/6/15.,3,500,,, +CO14162,524513,AFH,8/20/2014,"During an unannounced monitoring visit on 8/20/14, the local licensing authority determined that Licensee had no written prescription orders or self-administration orders for Resident #1's medications, which remained unlocked in the facility. Licensee was initialing the MAR daily but was not administering the medications. The Licensee was administering p.r.n. oxycodone 4 times daily to Resident #2 but not charting as required and did not follow doctor's orders in the administration of metoprolol for Resident #2. Licensee also did not sign administered medications for several days. Licensee received violations for these issues. Licensee's actions demonstrated a failure to follow pre-admission procedures; create and maintain accurate and truthful resident records; follow doctor orders; demonstate understanding of each resident's medication regimen; exercise reasonable precautions; and maintain residents' rights to a safe and secure environment.",3,400,,, +MV148663,524513,AFH,8/29/2014,"On or about 9/11/14, APS received a complaint that RP1 failed to treat RV with care during a transfer, which resulted in an injury. During the course of the investigation, APS determined that RP1 lifted RV from the floor to RV's bed. RP1 lifted RV by using a gait belt, but did not have anyone else assist RP1. RP1 then pushed RV across the bed, causing RV's head to hit the wall on the opposite side of the bed. RV's most recent assessment indicated increased care needs, including assistance with transfers, and RP1 was given an increase in pay to meet RV's care needs. RP1 never completed the preadmission screening assessment or initial care plan, as required by Oregon Administrative Rules. Facility's failure to provide appropriate service resulted in RV sustaining an injury. Facility's failure is a violation of resident's rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +MV145949,524513,AFH,1/26/2014,"On or about January 27, 2014, APS received a complaint that RP1 failed to follow physician's orders for RV. During the course of the investigation, APS substantiated the following: In 12/13, RV visited family for two weeks. RV did not have a self-medication order but RP1 did not arrange medication assistance for RV. RV returned to the facility with medications missing and unaccounted for. RV had p.r.n. orders for two pain medications. RP1 did not follow doctor orders and instead administered them as regularly scheduled medication. Large amounts of this pain medication disappeared and then some reappeared but not all missing medications were accounted for. RP1 did not always document on the MAR the reasons for giving p.r.n. pain medications' or results. RV received a self-medication order for the doctor which RP1 did not follow and did not allow RV to store medications in RV's room as required by rule. RV's primary care physician had plans to rescind the self-medication order based on RP1's concerns. RP1's failure to follow doctor's orders and failure to follow OARs are a violation of resident rights, and constitute both neglect and financial exploitation, which are considered forms of abuse.",3,,,,Neglect +CO14239,524513,AFH,12/2/2014,,3,250,,, +MF134359,524531,AFH,9/10/2013,"It was reported that on or about September 10, 2013, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee was rude to RV1 and would yell at RV1. Licensee would threaten RV1 with eviction or nursing home placement. Licensee's failures are a violation of Oregon Administrative Rules and is considered verbal/mental abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Verbal/Mental abuse +MS152638A,524531,AFH,8/31/2015,"On or about September 1, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV1) and Resident #2 (RV2) from inappropriate verbal communication. + +During the course of the investigation, RV1 reported that he/she often cried when RV1 experienced physical pain. RV1 reported that Licensee (RP1) had called him/her a _x001A_cry baby_x001A_. RV1 also stated that he/she had heard RP1 say, _x001A_Oh, poor baby_x001A_ when RV1 cried. RV1 felt that RP1 was making fun of his/her response to pain. Witness #4 (W4) added that RP1 and Reported Perpetrator #2 (RP2) _x001A_fight constantly_x001A_ with each other. RV1 was observed lying in his/her bed trembling while RP1 and RP2 were fighting. RV1 also reported that he/she had heard RP2 yell at Resident #2 (RV2). RV1 described the tone of the interaction as _x001A_mean_x001A_. + +Additionally, during the course of the investigation, APSS reviewed RV1_x001A_s care plan which indicated that RV1 liked to stay in RV1_x001A_s room and watch TV. RV1 reported that RP2 programmed RV1_x001A_s television to shut off at a certain time each night, even when RV1 wanted to watch TV. On one occasion, RP2 told RV1 that RP2 was going to bed and that RP2 would not get up and take care of RV1. RV1 was afraid that he/she would not receive assistance during the night. + +Furthermore, RV1 and Witness #3 (W3) voiced fear that RP1 and RP2 had listened to the interviews with the APSS, that RP1 and RP2 would find out what had been reported and that RP1 and RP2 would retaliate. + +RP1 and RP2 failed to provide a safe environment for RV1 and RV2. The failure is a violation of resident rights and constitutes verbal/emotional abuse.",2,,Substantiated,Substantiated,Verbal/Mental abuse +MS152638B,524531,AFH,8/31/2015,"On or about September 1, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #3 (RV3) from physical harm. + +During the course of the investigation, Adult Protective Services Specialist (APSS) reviewed RV3_x001A_s care plan. RV3_x001A_s care plan indicated that, _x001A_Staff is to fully assist in all transfers, have RV3 slide forward in RV3_x001A_s chair, then RV3 will have staff put staff hands under RV3_x001A_s arms (never holding the arm itself) and remind RV3 where you want RV3_x001A_s arms to go_x001A_._x001A_ + +APSS also reviewed facility Incident Reports related to RV3. On August 18, 2015, RV3 sustained a skin tear to RV3_x001A_s right arm above the elbow when Witness #1 (W1) pushed RV3_x001A_s right arm. On August 31, 2015, RV3 sustained a skin tear on his/her upper left arm when staff moved RV3 up in his/her bed. + +The facility failed to follow RV3_x001A_s care plan resulting in RV3 sustaining skin tears on two separate occasions. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +MS152465,524531,AFH,8/14/2015,"RV has multiple treatment needs, including falls. RV frequently gets out of bed and falls to the floor, four, five or six times a day. RV is unhappy with his condition. RP1 becomes frustrated and tells RV that RP1 and staff ""can't keep getting you up because you are killing us."" RP2 reportedly yelled at RV. RP3 is also reportedly rude to RV. RV acknowledged calling RP3 ""a bitch"" during one exchange.",2,150,,Substantiated, +AL151988,524535,AFH,5/29/2015,"Reported Victim #1 (RV1) was a resident of Licensee's adult foster home. RV1 suffered a decline in his/her health resulting in RV1 becoming anxious, confused and experiencing potential hallucinations. On May 28, 2015 RV1 wandered alone from the foster home after exhibiting confusion and anxiety for several hours. RV1 was located by Witness #1 who contacted law enforcement. RV1 was escorted back to the facility. Due to RV1's medical and health decline, he/she is no longer safe to go outdoors without supervision. The facility failed to provide a safe and secure environment.",2,,,, +AL148690,524543,AFH,2/28/2014,"It was reported that on or about February 28, 2014, Licensee failed to assure Resident #1 (RV1) was safe. RV1 liked to go on walks, but would get disoriented as a result of his/her medical condition. RV1 had a history of walking until he/she got lost. On February 28, 2014, RV1 exited a public transport vehicle and wasn't found until March 1, 2014, in a rural area located along train tracks. Licensee's failures are are considered neglect of care and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +CO14097,524544,AFH,1/30/2014,"Unqualified cargiver worked alone on December 17, 21, and 22 of 2014. Licesee failed to ensure a qulified caregiver was present 24 hours per day as required. FOD sent to LLA",2,,,, +RD149270,524544,AFH,11/7/2014,"On or about November 7, 2014, Adult Protective Services (APS) received a complaint that the facility failed to provide appropriate care for RV. During the course of that investigation, APS substantiated the following: RV has pressure wounds in the peri-area, the hip area, and on one foot. RV needs full assistance with transfers and repositioning and is incontinent of urine and bowels. Substitute caregivers leave the home at 7:30pm and return at 7:30am, and during those hours, RP1 and W3 provide care to residents. In the morning several times over the past month, RV has been found with soiled and soaked incontinent supplies, wet bedding, and wet clothing that is cold to the touch. Although RV is checked around midnight each night and repositioned/changed, the facility does not change RV's incontinent supplies again until a caregiver comes the following morning. RV is left in his/her soiled and wet garments between three and eight hours at a time. Facility is to reposition RV every two hours; RV's care plan does not indicate this. Facility's failure to assist RV at night to reposition, toilet, and/or change soiled incontinence supplies is a violation of resident rights, constitutes neglect, and is considered abuse.",3,400,,,Neglect +RS149237,524547,AFH,11/1/2014,"On or about November 12, 2014, Adult Protective Services received a complaint that the facility failed to provide an adequate medication system. During the course of the investigation, APS substantiated the following: during a long holiday weekend, RV1 ran out of his/her narcotic pain medication because RP2 had not called in a refill in a timely manner. As RV2 takes the same kind of medication, but at a different dosage level, RP2 used RV2's medication and cut the pill in half, giving RV1 the medication so that RV1 would not go without. Also, when RV2 ran out of medication, RP2 would take 2 of RV1's medications and give it to RV2. For several months, RP2 continued to use one resident's medication for the other resident when either RV1 or RV2 would run out. RP2 did not report this abuse (financial exploitation) immediately but, after several months, did alert the doctor. The Medication Administration Records (MARs) for both RV1 and RV2 indicate that there were times when both RV1 and RV2 went without their narcotic pain medication. Both RV1 and RV2 deny going without pain medication or experiencing pain. Licensee was unaware that this was going on until the day RP2 reported it to the doctor. RV1's failure to make a reasonable effort to protect both residents from financial exploitation is a violation of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +CO15179,524599,AFH,8/31/2015,CONDITION PLACED ON LICENSE ON 08/28/15. BOTH CO-LICENSEES INDIVIDUALLY SUBMITTED WRITTEN NOTICES OF VOLUNTARY SURRENDER. NO ACTION TO REVOKE/NON-RENEW LICENSE NEEDED. MATTER CLOSED 09/04/15.,4,,,, +CO15178,524599,AFH,8/31/2015,"Condition #AFHCD15-015 served Friday, August 28, 2015. Restriction of admissions; restricted Marcos Ruiz from premises and from providing care; restricted Rosa from providing direct care; and back-up provider must have full access and assume responsibility for oversight and staffing of home.",3,0,,, +ES152606,524599,AFH,8/8/2015,"On or about August 26, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV) from inappropriate sexual contact. + +Reported Perpetrator #2 (RP2) and Witness #2 (W2) are co-licensees of an adult foster home located 1909 Grove Street, Eugene, Oregon. During the course of the investigation, RP2 acknowledged that he had engaged in inappropriate sexual contact with RV on or around August 8, 2015. . + +Any significant incidents that relate to the health or safety of a resident must be documented. The AFH Incident Report or its equivalent was not prepared and signed by facility staff until August 26, 2015. + +RP2 advised W2 of the incident on or about August 14, 2015. RP2 failed to report the suspected abuse. W2 failed to immediately report the suspected abuse to the investigative authority and failed to contact law enforcement when abuse was suspected. W2 contacted the Department on or about August 26, 2015, approximately 12 days after becoming aware of the incident. + +RP2 engaged in sexual activity with a facility resident. RP2 as a Licensee failed to protect RV from inappropriate sexual contact. RP2_x001A_s failure is a violation of resident rights and constitutes sexual abuse as defined in Oregon Administrative Rule 411-020-0002(1)(e)(D). + +RP2 and W2 failed to demonstrate good judgment and a clear understanding of their responsibilities, failed to timely report abuse/suspected abuse to the Department and law enforcement, and failed to provide a safe environment for RV. The failures of RP2 and W2 as co-licensees are violations of resident rights, is considered neglect and constitutes abuse.",3,,Substantiated,Substantiated,Sexual abuse +CO14031,524618,AFH,1/30/2014,"On January 30, 2014, the licensor made an unannounced visit to the licensee's adult foster home (AFH). During the visit the licensor learned that the caregiver on duty (MA) did not have an approved criminal records check as required. Upon further inspection it was discovered that MA had not been oriented to the AFH and had not completed the caregiver preparatory workbook as required. MA disclosed to the licensor that she/he had worked alone at the AFH from 10:30am 1/26/2014 through 10:30am 1/29/2014. The licensee's conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules.",3,250,,, +MV149096,524618,AFH,10/29/2014,"It was reported that on or about October 29, 2014, Licensee failed to protect RV from financial exploitation. RV1 had purchased $200 in meat to have at the Adult Foster Home (AFH). RP1 had disposed of the meat without RV1's permission. Licensee's actions are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Financial abuse +RS133536,524622,AFH,6/13/2013,"It was reported that on or about June 13, 2013, Licensee failed to provide an adequate medication system. When Licensee admitted Resident #1 he/she failed to count Resident #1's medications but signed the ""counted medication list"" as though he/she did count the medications. As a result Resident #1 did not receive his/her medications as ordered. Wrongdoing on the part of the licensee was substantiated.",2,,,, +BH120046A,524632,AFH,5/11/2012,"It was reported that on or about May 11, 2012, Licensee failed to provide appropriate transportation services for Resident #1 (RV1). Licensee sent RV1 who was unable to communicate verbally to the hospital using the medical transport program. RV1 was sent with a note explaining his/her symptoms and did not have an escort. Additionally, Licensee did not contact RV1's family to inform them he/she was sent to the hospital. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +MV134600A,524663,AFH,9/13/2013,"On or about October 3, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3), Reported Victim #4 (RV4) and Reported Victim #5 (RV5) from inappropriate verbal comments. On or about September 13, 2013, RV4 requested breakfast. Reported Perpetrator #2 (RP2) suggested that RV4 wait until Witness #1 (W1) arrive at the adult foster home (AFH). RV4 expressed that he/she was not willing to wait and used profanity. RP2 expressed h/h disliked the use of profanity. RV1 heard RP2 tell RV1 that RV1 ""was selfish"" and ""only thinking of myself."" RV2 observed the argument and was ""upset"" as a result. The licensee failed to protect RV's from violation of resident rights. The failure is a violation of Oregon Administrative Rule.",2,,,, +MV134600B,524663,AFH,9/13/2013,"On or about October 3, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to assure resident rights for Reported Victim #1 (RV1). Reported Perpetrator #2 (RP2) entered into RV1's bedroom without permission and removed RV1's magazines and personal papers and recycled them. The licensee failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO15099,524663,AFH,5/20/2015,,3,150,,, +CO14001,524690,AFH,12/19/2013,Licensee failed to have a qualified caregiver in the AFH - mandatory UPDATE: FOP sent on 7/30/14,3,250,,, +CO14018,524705,AFH,1/2/2014,"Licensee financially exploited Resident #1, Licensee's failures are a violation of Oregon Administrative Rules (OARs) is considerd financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,,,Financial abuse +MV145919A,524705,AFH,1/28/2014,"It was reported that on or about January 28, 2014, Licensee failed to provide a safe medication administration system. Licensee's failures are a violation of Oregon administrative rules. Wrong doing on the part of the Licensee was substantiated.",2,,,, +KF150821,524709,AFH,4/6/2015,"The Department received a report that Licensee failed to provide a safe and secure environment for RV. When interviewed, RV1 indicated that the television constantly has on shows depicting violence, the children in the home are loud and that the RP1 yells at the children and it scares RV1. RP1 admitted that sometimes he/she does yell at the children in front of RV1. The facility failed to provide care and supervision in a home-like atmosphere.",2,400,,, +MV146365,524735,AFH,3/13/2014,"On or about March 13, 2014, the Department received a complaint that alleged Licensee (RP) had failed to provide Resident #1 (RV) with adequate care and services. The investigation found that RP had treated a large skin tear and older leg wounds him/herself without obtaining written orders from or consultation with RV's medical professional; RP canceled RV's medical appointments on more than one occasion; RP failed to provide sufficient staffing levels to meet RV's needs; RP failed to update RV's care plan timely; RV did not receive diabetic foot care for approximately seven (7) months; RP failed to maintain resident narratives prior to March 2014; and failed to notify RV's medical professional when RV experienced a change in condition. Licensee failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +MS152988,524743,AFH,10/1/2015,"It was discovered that on or about October 1, 2015, Licensee failed to provide appropriate care to Resident #1. Resident #1 had developed an open skin injury on his/her back side. Resident #1 required two person assistance with repositioning. Resident #1 did not receive two person assistance with repositioning because Licensee didn't have two people on duty to assist Resident #1. Resident #1's care plan indicated Resident #1 was to be repositioned every hour but he/she was only repositioned every couple hours. Licensee's failures are a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +HB134336,524752,AFH,9/6/2013,"On or about September 6, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to administer a medication as ordered to Reported Victim (RV). RV has an order for mood/behavior medication to be administered by mouth every six hours up to three times a day as needed. Reported Perpetrator #2 (RP2) and RP1 acknowledge changing the order to administer the medication at 9am, 1pm and 6pm. This is documented on RVs medication administration record. The licensee failed to administer medication as ordered to the RV. The failure is a violation or Oregon Administrative Rules.",2,,,, +MS148281B,524792,AFH,8/26/2014,"It was reported that on or about August 28, 2014, Licensee failed to provide Resident #1 with a adequate medication administration system. Licensee failed to ensure Resident #1's medication administration record was initialed after each medication administration as required. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO14196,524799,AFH,9/19/2014,"Licensee did not exercise reasonable precautions against the above conditions, which may have threatened the health, safety, or welfare of Resident #1, Resident #2, and Resident #3. Licensee has failed to submit a complete renewal application, failed to provide a safe medication administration system, failed to ensure resident records and facility records were complete and current, and has failed to correct violation issued by the Local Office Licensing Authority. Wrongdoing on the part of the Licensee has been substantiated.",4,,,, +CO15155,524839,AFH,7/30/2015,Provider had no qualified caregiver in the home for the second time. Mandatory civil penalty issued.,3,300,,, +NB148698A,524846,AFH,9/26/2014,"On or about September 26, 2014, a complaint was received that alleged the facility had failed to protect Resident #1 (RV) from wrongful use of a restraint. RV became upset during a verbal dispute with Reported Perpetrator #2 (RP2) about RV_x001A_s pet. After the exchange, RV wanted a piece of writing paper from the office at the adult foster home (AFH). When RV attempted to ambulate down the hall to that portion of the AFH using his/her assistive device, RP2 blocked RV_x001A_s access. When RV continued to move forward RP2 placed his/her hands on RV_x001A_s shoulders. The investigation determined that RP2 had physically restrained RV. RP2_x001A_s actions are considered wrongful use of a physical restraint and constitute abuse. Responsibility for the abuse of RV was apportioned to RP2. It was further determined that the facility failed to provide a safe environment. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",2,,Not Substantiated,Substantiated,Restraints +NB148698B,524846,AFH,9/26/2014,"Resident #1 moved into Licensee_x001A_s (RP1) adult foster home (AFH) with his/her cat. RP1 and Reported Perpetrator #2 (RP2) knew RV had a cat at the time RV admitted to the AFH. RV reported that his/her cat was very important to him/her. RP1 and RP2 made frequent complaints about RV_x001A_s cat. The litter box for RV_x001A_s cat was in RV_x001A_s bedroom. During the course of the investigation, RP2 stated that RP2 was upset that he/she had to clean the litter that was all around RV_x001A_s room. RP2 told RV that his/her cat would have to go outside. RV reported that he/she felt that RP2 had used the cat to purposefully upset RV. + + + +After the dispute with RP2 about RV_x001A_s cat, RV wanted a piece of writing paper from the office at the adult foster home (AFH). When RV attempted to ambulate down the hall to that portion of the AFH using his/her assistive device, RP2 blocked RV_x001A_s access. When RV continued to move forward RP2 placed his/her hands on RV_x001A_s shoulders. RV communicated to RP2 that he/she had assaulted him/her and RV went to call the police. RP1 acknowledged that she walked up to RV and asked RV, _x001A_Do you really want to live here [AFH]?_x001A_ When RV responded, _x001A_yes_x001A_, RP1 advised RV to hang up the phone. RV was dependent on the care of RP1 and RP2. RV was fearful that he/she would end up homeless and without care. The investigator observed that RV became tearful on several occasions when he/she spoke about the incident. + + + +The investigation determined that RP1_x001A_s and RP2_x001A_s conduct is considered a violation of resident rights and constitute emotional abuse. Responsibility for the abuse of RV was apportioned to both RP1 and RP2.",2,,Substantiated,Substantiated,Verbal/Mental abuse +NB148992,524846,AFH,10/21/2014,"It was reported that on or about October 21, 2014, Licensee failed to provide a safe environment for Resident #1, Resident #2, and Resident #3. Resident #1 gave Reported perpetrator #2 $40.00 cash for wine and Reported Perpetrator #2 did not bring Resident #1 his/her wine or the money he/she had given Reported Perpetrator #2 to purchase the wine, and 3 empty wine bottles were discovered in Reported Perpetrators #2's room. Additionally, Resident #1, Resident #2, and Resident #3 had narcotic pain medications come up missing although the investigator was unable to determine who took the narcotic pain medications. Reported Perpetrator #2 failures are considered financial exploitation and constitutes abuse. Licensee's failures are considered financial exploitation and constitute abuse. Wrongdoing on the part of the Licensee is substantiated.",2,,Substantiated,Substantiated,Financial abuse +CO14125,524847,AFH,7/9/2014,Failed to install or maintain functional smoke alarms (x4),3,1000,,, +BO147724,524847,AFH,6/10/2014,"On or about June 11, 2014, it was alleged that Reported Perpetrator (RP) faile to provide a safe medication administration for Reported Victim (RV). The medication administration record (MAR) for RV for the months of May and June 2014 demonstrate the prescribed pain medication for RV was not being documented and administered as ordered. The licensee failed to provide a safe medicaiton administration system for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14205,524864,AFH,10/9/2014,Licensee received an AFH license 11/6/13. Her background check expired 7/17/14. She did not submit a new background check until 10/8/14. She worked alone on 10/9/14. LLA submitted for mandatory civil penalty. SENT A FOB TODAY.,3,250,,, +CO14238,524909,AFH,12/2/2014,"On or about 11/12/14, the local licensing office conducted an unannounced renewal inspection and found multiple issues including 4 which received violations: provider had no approved background check, one carbon monoxide device did not function, no sharps container was used to dispose of syringes/needles, and provider was using propane heaters/lanterns inside the home.",3,250,,, +RD146786,524953,AFH,3/25/2014,"On or about April 10, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). It was normal for RV to take a walks for approximately a half an hour. RV's service plan dated 12/27/2013 notes that RV has memory issues. RV left the facility and was gone approximately two hours before RP began to search for RV. RV arrived back at the facility on his/her own. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS151078,524955,AFH,3/13/2015,During the times mentioned in this notice Reported Perpetrator #1 (RP1) was responsible for providing care and services to RV1. RV1 developed a serious skin condition while under the care of RP1. RP1 was given directions from medical professionals on how to provide appropriate care for RV1 skin condition. RP1 failed to follow medical professionals care instructions; failed to follow medication orders for RV1 skin cream; failed to ensure RV1 made it to his/her medical appointments; failed to ensure missed/cancelled appointments were rescheduled; and failed to make follow up appointments when requested by RV1s physician.,3,400,,,Neglect +MS151878,524955,AFH,7/9/2015,"It was reported that on or about July 9, 2015, Licensee failed to provide appropriate care and services to Resident #1 (RV1). Licensee failed to ensure RV1 made it to his/her medical appointments as recommended by medical professionals. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +MS152350,524955,AFH,8/5/2015,"On or about August 5, 2015, Licensee failed to provide appropriate care and services to RV1. Licensee's failures are a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,550,Substantiated,Substantiated,Neglect +CO16002,524955,AFH,1/5/2016,Failure to have qualified caregiver on site working 24 hours per day; occurred twice; issued $500 mandatory civil penalty.,3,500,,, +BO152800,524964,AFH,6/4/2015,"On or about September 1, 2015, Adult Protective Services (APS) received a complaint that the facility failed to administer ordered medication to RV. During the course of the investigation, APS substantiated that Licensee discontinued RV's medication without a written order from a physician. W1 took RV to his/her physician, who ordered the medication to continue. RP then administered medication as ordered. Licensee's failure to follow physician orders is a violation of OARs.",2,,Substantiated,Substantiated, +HB149041,524992,AFH,10/24/2014,"On or about October 24, 2014, the Department conducted a facility complaint investigation. During the investigation, it was discovered that Licensee had failed to maintain a current and accurate Medication Administration Record (MAR) for Resident #1 (RV) and failed to obtain current written orders for all medications being dispensed to RV. Licensee's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.",2,,,, +FL152938A,525025,AFH,9/24/2015,"RV1 moved into Licensee's adult foster home on June 8, 2015. RV1 requested RP1's assistance with cleaning his/her medical device. RP1 stated that assisting RV1 clean his/her medical device required delegation and refused to assist RV1 with the task. When interviewed, Witness #2, Witness #3 and Witness #4 all stated that the cleaning of RV1's medical device did not require delegation. On August 21, 2015 RP1 requested authorization for RV1 to complete the cleaning of his/her medical device independently. The facility waited in excess of two months to request approval from RV1's physician for RV1 to be independent with this task. In addition, on August 21, 2015 RP1 requested that RV1 be independent with his/her medication administration. RP1's request was approved by RV1's physician. Facility documentation indicates that RV1 had difficulty waking up to take his/her medications and that facility staff had to cue/prompt RV1 to take his/her medications on numerous occasions. RV1 indicated that he/she did not request to be independent with his/her medications. The facility failed to exercise reasonable precautions against any conditions that threatened the health, safety or welfare of RV1 and failed to provide a safe home-like environment. Licensee's failures are considered neglect of care and constitute abuse under the Oregon Administrative Rules (OAR's).",2,,,,Neglect +FL152938B,525025,AFH,9/24/2015,RV1 was a resident of Licensee's adult foster home. RP1 admitted that he/she has told RV1 that RV1 uses his/her disabilities to take advantage of people. RV1 indicated that he/she gets upset when RP1 notifies him/her that he/she does not need any assistance. RP1 failed to provide care and supervision in a home-like environment.,2,,,, +AL150999,525029,AFH,7/29/2014,"On or about August 15, 2014, APS received a complaint that the facility failed to protect the RV from financial exploitation. During the course of the investigation, APS substantiated the following: RP3 came to the facility to visit RP2 as they knew each other for several years. By July 2014, RP3 had ""befriended"" RV and on 7/24/14, RV asked RP3 to buy cigarettes for him/her using RV's debit bank card. RP3 returned to RV with a few items bought at a discount store, along with cigarettes. A few days later, RV discovered he/she did not have money in his/her bank account to pay the monthly rent and on 7/29/14, a complaint was made to law enforcement that RP3 used RV's debit bank card fraudulently. RP3 admitted to law enforcement that he/she used RV's debit bank card without RV's authorization. RP3's actions are considered financial exploitation, a type of abuse.",3,,Not Substantiated,Not Substantiated,Financial abuse +MV150729A,525081,AFH,12/6/2014,It was alleged that the facility failed to provide a proper medication management system. Facility documentation determined that RV1's medications were not documented correctly on his/her Medication Administration Record (MAR's). Facility documentation also indicated that RV1 did not receive his/her medications per doctors orders. Licensee's failures are a violation of the Oregon Administrative Rules.,2,,,, +HB152282,525087,AFH,7/30/2015,"It was reported that on or about July 30, 2015 Licensee failed to maintain an adequate medication administration system. Licensee's failure to maintain an adequate medication administration system is a violation of AFH OAR's. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO14138,525104,AFH,7/25/2014,Condition issued 8/1/2014. Department received information from LO on 10/7/2014 that demonstrates the licensee has maintained substantial compliance. LO requests that condition be removed. Order of Withdrawal of Condition sent through certified mail on 10/16/2014.,3,0,,, +GP152874A,525104,AFH,9/21/2015,"Reported Victim #1 (RV1) was a resident of Licensee's adult foster home. RV1 had been diagnosed with a cognitive deficit disorder. RV1's screening and assessment dated August 13, 2015 stated that RV1 wandered on occasions. RV1's care plan dated August 30, 2015 indicated that caregivers should keep tabs on RV1 throughout the day, monitor RV1's whereabouts weather inside or outside of the home and that RV1's wandering outside of the home is a problem and can jeporadize his/her safety. On September 16, 2015 RV1 left the facility with RP1 following him/her. RP1 contacted law enforcement for assistance with returning RV1 to the foster home. On September 20, 2015 RV1 eloped independently from the adult foster home and was walking alone in the community for approximately four hours. RV1 was assisted by a concerned citizen in the community, who contacted law enforcement for help. Law enforcement contacted Witness #1 to pick up RV1 and return him/her to the foster home. Licensee failed to provide a safe and secure environment and failed to exercise reasonable precautions against any conditions that presneted a threat to RV1's health, safety or welfare. Licensee's failures are considered neglect of care and constitute abuse.",3,400,,,Neglect +CO15171,525117,AFH,8/21/2015,Provider owns two homes next to each other. Staffing plan states that there will be an awake caregiver 24 hours per day and also another caregiver in the home sleeping. Two instances where only 1 caregiver went from one home (leaving residents in that home alone) to check on residents in the other home.,3,500,,, +AL151173B,525117,AFH,10/13/2014,"On or about October 13, 2014, Adult Protective Services (""APS"") received a complaint that the facility failed to follow RV's service plan. During the course of the investigation, APS determined the following occurred: RV's care plan indicates RV is to be checked every 2 hours, throughout the night. On or about July 31, 2014, RV fell out of bed and RP2 failed to follow the care plan and check on RV every 2 hours. RV was checked at 3:00am but there is no indication RV was checked again until at least four hours later. Facility could not be sure how long RV had been lying on the floor of RV's bedroom. RV had a small bump on his/her right ear, small bump on back of right shoulder, and scrape on right thigh. RP2's failure to follow the care plan is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +AL152384,525117,AFH,7/29/2015,"It was reported that on or about July 29, 2015, Licensee failed to provide a safe environment for Resident #1. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +NB150265A,525119,AFH,2/17/2015,"On or about February 17, 2015, the Department received a complaint which alleged the facility had failed to protect Resident #1 (RV1) and Resident #2 (RV2) from theft of medications. During the course of the investigation, APS substantiated that RV1 was missing 27 pills from his/her medication bottle. APS also determined that 59 tablets of RV2_x001A_s narcotic pain medication had been replaced with an over-the-counter (OTC) pain reliever. It is unclear who took the medications. Theft of medications is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +NB151235B,525119,AFH,5/12/2015,"On or about May 12, 2015, the Department received a complaint which alleged the facility had failed to protect residents from intimidation and inappropriate verbal communication. + + + +The Adult Protective Services Specialist determined that Licensee (RP) maintained a strict routine in his adult foster home (AFH) and wanted everything completed in a certain manner. RP acknowledged that he can be stern but he also stated that he knows the best way to accomplish everything in an efficient manner and it was important that his schedule was followed. + + + +Witness #1 (W1), Witness #3 (W3), Resident #1 (RV1) and Resident #5 (R5) all reported that RP had spoken to residents in an aggressive, rude and demanding manner. W3 also communicated that RP demonstrated little patience or tolerance when RP_x001A_s schedule was interrupted. RV1 stated that he/she would not activate RV1_x001A_s call button, even when RV1 needed assistance with his/her incontinent garment at night because RP had previously spoken meanly to him/her. RV1 reported that he/she felt scared and scolded, afraid of how RP would react when RP was awakened. RV5_x001A_s statements supported that RP did not like being awakened during the night. RV5 avoided asking RP for assistance because RP acted like it was an inconvenience. RP admitted to W3 and directly to APS that he can be a little short with residents. + + + +RV1 reported that RP brushed the residents_x001A_ teeth and hair because there wasn_x001A_t enough time for them to do it themselves. Additionally, RV1 stated RP often selected clothing for RV1 and he/she could not deviate from what RP decided. It was further reported that all residents eat at a certain time. If a resident did not eat quickly enough RP removed the resident from the table, whether they were done eating or not. W3 reported that RP took Resident #3_x001A_s (RV3) food away when RV3 would not stop clicking RV3_x001A_s spoon against the side of his/her bowl. + + + +Additionally, during the course of the investigation it was discovered that residents were directed to their rooms at 7:30pm. If residents did not want to go to bed, those that had televisions could watch TV in their rooms but must do it very quietly as RP did not like noise. RV1 and RV5 reported that residents had to remain in their rooms until RP came to get them up in the morning which was sometime between 7am and 8am. At that point, RP usually began assisting residents, in a specific order. RP acknowledged that 7am is still quiet time in the AFH. RV1 also reported that residents were transferred to their recliners at 10am which was also confirmed by RP. + + + +Licensee failed to provide a home-like environment; failed to treat residents with dignity and respect; failed to allow all residents freedom of choice; used residents_x001A_ access to food and sufficient time to eat a meal as a tool to control resident behavior; and failed to provide a safe environment. + + + +Licensee_x001A_s failure to provide an environment free of intimidation is a violation of residents_x001A_ rights and constitutes verbal/emotional abuse. Licensee_x001A_s failure to allow residents to freely choose their own schedules and where in the AFH they could be at certain times is a violation of residents_x001A_ rights and constitutes involuntary seclusion.",3,450,Substantiated,Substantiated,Verbal/Mental abuse +CO14180,525155,AFH,9/11/2014,"Licensee had a substitute caregiver working five consecutive days/nights per week. Although Lefty Domingo had turned in an RM application, she had not been approved as an RM yet. Licensee also had Alma Tovar working on the weekend with no criminal background check, no orientation, and no workbook. Other issues in the home: MARs signed by Licensee who did not administer the medications, MARs not signed, no orientation for some residents, no signed house policies or bill of rights for one resident and incomplete screenings for 3 residents. FOD E-MAILED TO LLA AND PROVIDER",3,450,,, +CO15068,525155,AFH,3/27/2015,,3,550,,, +MV151135,525155,AFH,4/27/2015,"On or about April 30, 2015, Adult Protective Services received a complaint that the facility failed to protect RV from harassment. During the course of the investigation, APS substantiated the following: RP gave, withdrew, and then gave again an involuntary move out notice to RV. RP had a verbal altercation with RV, did not immediately leave RV's room when directed to do so, returned and threw a move-out notice on RV's bedroom floor, and continued to argue with RV. RV's blood pressure rose to dangerously high levels and RV was transported to the ER at approximately 7:30 pm on 04/27/15, where RV was seen for hypertension/headache, treated for headache, and released shortly after 12:00 a.m. on 4/28/15. The facility failed to protect RV from harassment. The failure is a violation of resident rights and constitutes verbal abuse.",2,,,,Verbal/Mental abuse +MV152699,525155,AFH,9/3/2015,"On or about September 3, 2015, Adult Protective Services (""APS"") received a complaint that Licensee failed to properly manage RV's medications. During the course of the investigation, APS determined that on or about September 2, 2015, RV experienced outward symptoms of a treatable lung ailment and went to the local emergency room for treatment. RV was prescribed a medication to start that day in order to treat the ailment. RV took the prescription back to the AFH that day and gave it to W2 to get the medication. W2 was unable to get the medication as the facility fax machine was not working and W2 was unable to make contact with RP. On September 3, 2015, after RV had missed 3 doses of the medication, W2 contacted RP and made arrangements for RV to get the medication. Licensee's failure to follow doctor orders and have medications on site are a violation of resident rights, are considered neglect, and constitute abuse.",2,,Substantiated,Substantiated,Neglect +NB150411,525165,AFH,2/27/2015,"On or about February 27, 2015, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care and services to Reported Victim (RV). During one incident, RV's O2 levels were in the 70's and 80's which was too low. Reported Perpetrator #2 (RP2) did not notify RV's physician or contact emergency personnel. RV has a call bell to ring whenever he/she needs assistance. RV stated that he/she would have to wait for an extended period of time before RP2 would respond. RV's screening and assessment notes that RV requires assistance with transferring. RV stated that he/she is left alone most of the day in his/her bedroom. During a separate incident, RV spent at least 24 hours with low O2, this increased RV's anxiety. The licensee failed to provide appropriate care and services to RV. The failure is a violation or resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +KF148933,525166,AFH,10/15/2014,"On or about October 16, 2014, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). RP drove RV to RV's doctors appointment. Witness #1 (W1) smelled alchohol on RP. Law enforcement was contacted. Witness #2 (W2) smelled alcohol on RP. W2 stated that RP scored a 5/6 on an HGN test, which would determine that RP was intoxicated. It was W2's opinion that Rp was attempting to cover the alchohol smell with perppermint gum. W2 informed RP that if RP drove off the premises then RP would be arrested for driving under the influence. RP contacted Witness #3 (W3) to pick up RP and RV.",2,,,, +KF153322,525166,AFH,10/28/2015,"On or about October 28, 2015, the Department received a complaint which alleged the Licensee (RP) had failed to provide appropriate care and services for Resident #1 (RV). + + + +Resident #1 (RV) was incontinent of bowel and bladder as documented in RV_x001A_s Resident Assessment completed by the Licensee on May 22, 2015. RV required assistance with mobility which was documented in both the Resident Assessment dated May 22, 2015 and RV_x001A_s Care Plan dated June 16, 2015. A nursing note entry made by home health dated June 30, 2015 indicated that RV required the assistance of 1-2 people for ambulation and transferring. RV also required wound care for a stage III pressure ulcer on RV_x001A_s sacrum. + + + +Due to RV_x001A_s incontinence and RV_x001A_s mobility concerns, Licensee acknowledged to the Adult Protective Services Specialist (APSS) that she had two rules for RV: (1) RV must not get out of his/her recliner and (2) RV must not remove his/her incontinent garments. RV confirmed to APSS that Licensee said he/she could not get out of his/her chair. RV further shared with APSS that RV felt like a prisoner. + + + +Licensee reported that RV constantly broke her two _x001A_rules_x001A_ and not remember so Licensee began taking photographs to prove the behavior to RV. During the investigation, Licensee showed a number of pictures to APSS. These pictures were often taken while RV was still on the floor, hanging over the recliner, on or around the toilet and in various stages of undress. In at least one case the pictures were sent to RV_x001A_s family. + + + +RP recounted a specific occurrence when she required the assistance of another person to lift RV off the floor. In that instance, Licensee left the AFH to ask a neighbor for help in getting the RV back into RV_x001A_s recliner. + + + +Furthermore, RV stated that when he/she had to go to the bathroom, Licensee would tell RV to use his/her incontinent brief. RV further reported that he/she would hold his/her urine as long as possible. RV told the APSS that he/she would have to sit for long periods in his/her wet and soiled incontinent brief. A nursing note dated June 30, 2015, documented that home health was unable to locate a caregiver in the facility when RV needed toileting assistance. The home health staff assisted RV with his/her toileting needs. The caregiver was later found asleep in the AFH. + + + +Additionally, Witness #1 (W1) reported that RV had developed a yeast infection in the fold of skin on RV_x001A_s abdomen. RV had been prescribed a powder medication to treat the yeast infection but Licensee stopped applying the powder because it would cake up and roll down RV_x001A_s clothes. Licensee acknowledged to the Adult Protective Services Specialist (APSS) that she did not obtain an order from RV_x001A_s medical professional to discontinue the use of the medicated powder. Licensee also reported that instead of using the medicated powder, she began using a barrier cream without obtaining a physician_x001A_s order. W1 stated that RV_x001A_s yeast infection could have been easily resolved by keeping the area dry and using the medicated powder that had been prescribed to RV. + + + +Licensee restricted RV to his/her recliner; failed to maintain a safe medication administration system; failed to ensure RV_x001A_s privacy; failed to treat RV with dignity and respect; failed to have sufficient caregiving staff at all times to meet the twenty-four hour needs of each resident; and failed to ensure a qualified caregiver was present and available in the AFH at all times, twenty-four hours per day, seven days per week. Licensee_x001A_s failure to provide a safe environment is a violation of resident rights, is considered neglect and constitutes abuse.",3,250,Substantiated,Substantiated,Neglect +CO16062,525171,AFH,2/24/2016,Licensee scheduled two unqualified caregivers to work in the AFH alone. One had not been oriented to the AFH and one had no completed the Department's Preparatory Training Study Guide and Workbook. Mandatory CP sanction granted for $250.00,3,250,,, +JG153746,525180,AFH,8/24/2015,RV1 was a resident of Licnesee's adult foster home. RV1 developed a sore on his/her left heel and coccyx while at the foster home. RV1 was given a treatment for his/her wounds prior to consultation and orders from his/her doctor. The facility's failure is a violation of the Oregon Administrative Rules.,2,,,, +NB148728,525202,AFH,9/29/2014,"It was reported that on or about September 29, 2014, Licensee failed to provide a safe environment for Resident #1 (RV1). Reported Perpetrator #2 (RP2) ALLOWED Witness #1 (W1) access to the facility even though he/she knew W1 was not to be on the property. W1 accessed RV1's bank account information and used RV1's bank account information to pay W1's own bills and one of RP2's bills. Licensee's failure is a violation or Adult Foster Home Oregon Administrative Rules. RP2's failure is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +MF150136,525249,AFH,2/5/2015,"On or about February 5, 2015, APS received a complaint that facility failed to provide appropriate care. During the course of the investigation, APS substantiated that RV requires 24 hour care and has unscheduled toileting needs. RP1 is the only one that provides physical care to RV and changes and cleanses RV in the late morning. RP1 is not in the facility in the afternoon when RV has bowel movements and is not always available to return to the facility immediately, resulting in RV remaining in RV's feces for several hours at a time until RP1 returns. RV has sat in RV1's feces until the following day if RP1 is not able to return to the facility. Facility's failure to provide sufficient staffing to meet RV's care needs and failure to provide appropriate care and services is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +CO15255,525249,AFH,12/17/2015,"Applicant_x001A_s 10/29/2015 application remained incomplete as of 12/29/2015 and is void; Applicant does not have the equivalent of three (3) years of full time experience providing direct care as required, and has not supplied satisfactory references to the Department; Applicant submitted false or inaccurate information on both her initial license application and her Criminal Background Check request.",3,0,,, +MF151444,525249,AFH,6/3/2015,"RV1 and RV2 are residents of the adult foster home. Witness statements and facility documentation indicates that RP2 can be verbally ""harsh"" at times with the residents. RP1 has discussed RP2's communication style with him/her and RP2 is focused on improving communication between him/her and the residents. When interviewed RP2 stated that, ""I don't try to be short with any of the residents but I can get stressed at times."" The facility failed to provide a safe and homelike environment. The facility's failure is a violation of the Oregon Administrative Rules.",2,,,, +CO16070,525249,AFH,3/17/2016,,4,,,,Neglect +MF164446,525249,AFH,1/28/2016,"RV's electric wheelchair broke and needed repair. RV was given a manual chair, and stated s/he required assistance to push it due to pain. Facility believed RV could push his/her manual wheelchair, and requested a doctor order confirming RV could not push it his/herself. The facility has since closed.",2,,,, +MS152500,525249,AFH,8/17/2015,"RV's care plan requires full assist when RV is in the community because of RV's cognitive disorder and memory loss. RV has a history of eloping. Caregivers are to accompany RV during walks in the neighborhood, or when RV was otherwise in the community. Without supervision, RV gets lost. On 8/17/15 RV insisted s/he wanted to go out and was determined to leave. Facility staff tried to prevent RV leaving but RV said he would break the window if stopped. Facility decided to let RV go, making sure RV had his cell phone, which could be tracked. Facility staff did not follow RV because they felt RV would hide. RV left his/her cellphone at someone's house and could not be tracked. RV was gone from the facility for about three hours and was brought back by law enforcement. The facility is now closed.",3,,Substantiated,Substantiated,Neglect +MS164409,525249,AFH,1/26/2016,"RP2 yells at RV and has made the comment that it would be better if RV would go to the bathroom in RV's bed, so that RV would not have to be transferred. RP2 tells RV that ""RV has b.o. because RV sits in RV's chair all day."" RV is intimidated by RP2, and RP2 makes RV ""feel small."" The facility is now closed.",3,,Substantiated,Substantiated,Verbal/Mental abuse +CO15195,525251,AFH,9/21/2015,Expired background for cg Rita Grant,3,200,,, +CO15181,525252,AFH,8/31/2015,Provider did not have a smoke alarm with a battery in the living room. Husband had removed it the week prior and forgot to replace it.,3,250,,, +AL152252,525268,AFH,7/24/2015,"On July 24, 2015 RV1 and RV2 were sitting outside on the patio smoking cigarettes and began arguing over the placement of an ashtray. RV1 became ""territorial"" over the possession of the ashtray and when RV2 chose not to share the ashtray, RV1 hit RV2 in the forhead with his/her hand. Witness #1 indicated that RV1 can be ""territorial"" and wants things for himself/herself. RV2 contacted law enforcement and RV1 was cited for harassment. The facility failed to provide a safe and secure environment.",2,,,, +CO15225,525269,AFH,11/9/2015,failure to maintain qualifications and requirements for 2 caregivers.,3,500,,, +NB153172A,525277,AFH,10/10/2015,"RV1 and RV2 were residents of Licensee's adult foster home. RV1 and RV2 also shared a room in the foster home. Facility documentation indicates that RV1 and RV2 were aggressive toward one another on several occasions. On or about October 10, 2015 RV1 fell to the ground as he/she attempted to ambulate to the restroom in the dark. RV1 was transported to the hospital on October 12, 2015 and returned to the facility two days later with a back brace due to his/her injuries. RV2 made verbal threats of potential physical violence toward RV1. The facility failed to provide a safe environment and failed to update RV1 or RV2's care plan following numerous altercations and RV1's back injury. The facility's failures are violations of the Oregon Administrative Rules.",2,300,,, +NB153172B,525277,AFH,10/10/2015,"RV1 and RV2 were residents of the adult foster home. Facility documentation indicates that RV1 and RV2 have yelled at each other multiple times and that RV1 and RV2 are afraid of one another. In addition, RV2 has made verbal threats of physical injury toward RV1. The facility failed to institute any new interventions to prevent further verbal altercations between RV1 and RV2. The facility's failure is a violation of the Oregon Administrative Rules.",2,,,, +NB153172C,525277,AFH,10/10/2015,"RV1 and RV2 were roomates at Licensee's adult foster home. Witness interviews and facility documentation indicates that RV1 has thrown items at RV2, RV2 has made verbal threats toward RV1 and RV1 has pushed RV2 down. The evidence indicates that verbal altercations between RV1 and RV2 began immediately after they were moved into the same bedroom. No new interventions were instituted to prevent further physical or verbal altercations between RV1 and RV2. The facility failed to provide a safe and secure environment. The facility's failure is a violation of the Oregon Administrative Rules.",2,,,, +CO15210,525288,AFH,10/1/2015,Licensee's background check expired.,3,250,Substantiated,, +CO15202,525320,AFH,9/24/2015,Expired Background,3,1000,,, +HB159842B,525323,AFH,1/7/2015,"On or about January 7, 2015, it was alleged that Reported Perpetrator #1 (RP1) failed to appropriately care plan related to falls for Reported Victim (RV). RV has memory deficits due to his/her condition. RV is a fall risk due to his/her weakness in his/her legs and his/her inability to bear weight. RV was discovered on the floor by RV's bed around 4:00am on 10/16/14. The fire depatment was contacted and assisted RV back into bed. On 10/18/14 RV fell on the floor next to his/her bed at approximately 1:45am. RV complained of dizziness and was transported to the hospital for treatment. On 11/3/14 RV's primary physician ordered the use of bed rails for RV. On 12/10/14 Reported Perpetrator #2 (RP2) discovered RV on the floor near RV's bed in the morning. RV was transported to the hospital for treatment. The licensee failed to appropriately care plan related to falls for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO15226,525330,AFH,11/9/2015,Failure to maintain qualifications and requirements for Licensee and Resident Manager expired background checks,3,500,,, +MS150412,525354,AFH,2/27/2015,"It was reported that on or about February 27, 2015, Licensee failed to provide a safe medication administration system for Resident #1 (RV1). Licensee failed to have medication administration orders for RV1, Failed to have RV1's medications on hand when RV1 moved into Licensee's AFH, failed to conduct the requires assessment of RV1, failed to have a care plan for RV1, and failed to have medication administration records for RV1 as required.",2,,,, +CO15147,525354,AFH,7/21/2015,"Incident occurred at AFH located on Picadilly. However, good judgment and oversight is required at both homes. This AFH has been licensed for less than two years. Suspension #AFHSUS15-009 served via hand delivery on 07/24/15. Mr. Safotu was granted an Administrative Review which sustained the Department's action. File sent to DOJ on 08/14/15. On August 26, 2015, Deborah Salgado received an e-mail from Mr. Safotu stating that he was surrendering the AFH license for the home located on Innsbruck.",3,,,, +CO15149,525354,AFH,7/23/2015,Unqualified caregiver JC worked in the home unsupervised on 07/20/15.,3,250,,, +CO15150,525354,AFH,7/23/2015,MR. SAFOTU SURRENDERED LICENSE ON 08/31/15. NO FURTHER ACTION NEEDED. Revocation Not Needed.,4,,,, +CO15152,525354,AFH,7/24/2015,Held for action against Innsbruck home. Not needed. Voluntarily Surrendered - Suspension not needed,4,,,, +CO15257,525384,AFH,12/22/2015,"Licensee allowed multiple caregivers to work without approved background check. This has happened on multiple occasions in the past, but all in 2013 or prior. She also has another home with bcu issues.",3,250,,, +RS165109,525418,AFH,3/15/2016,"The facility applies essential oils to RV's body to treat for pain, and also use the essential oils into a breathing treatment for RV. RV's family has approved the use of the oils by the facility, but there is no physician order for these treatments, and they are not documented.",2,,,, +RS164981B,525418,AFH,3/6/2016,"RV is at risk of falling and uses a wheelchair. RV tends to ""wiggle out"" of h/h chair by using the remote to put the chair up and slide out. Facility staff secured RV in h/h chair by putting the footrest up, and putting the remote by the side of the chair where RV would have difficulty reaching it. The facility has since counseled all staff about the proper use of restraints.",2,,Substantiated,Substantiated,Restraints +RS164981C,525418,AFH,3/6/2016,"RV's physician prescribed a mood stabilizer on 2/25/16, with one 50g tablet to be administered at bedtime as needed. The facility administered the medication as ordered for three days, and then decided the medication was making RV tired and ""out of it, so administered half a tablet in the morning on 2/29/16 and half a tablet in the evening that same day. The facility did not obtain a physician order to change the administration of this medication.",2,,,, +MV150482,525432,AFH,3/5/2015,"Resident #1 (RV) is prescribed Dulcolax/Bisacodyl 10mg suppository to be administered if RV has constipation or no bowel movements in three days. If medication is not effective, caregivers are to see the next step in resident protocol. RV is prescribed Milk of Magnesia to be administered if unrelieved by Dulcolax suppository. RV is also prescribed a Fleet Enema/Phosphasoda Enema to be administered if step one and step two in the protocol are not effective. Caregivers are instructed to contact physician if there is no bowel movement in four hours after administering. + + + +On March 5, 2015, RV was transported to the hospital for treatment due to complaints of stomach pain and nausea. According to Emergency Department notes RV was admitted to the hospital due to constipation. RV stated that in the last couple of weeks he/she has had only small bowel movements of hard pebbles. RV noted that he/she had not had a bowel movement for one week. RV stated that he/she had not had an enema since 2/11/2015. + + + +Reported Perpetrator #2 (RP2) acknowledged that RV had not had a bowel movement for one week. RP2 stated that he/she had been giving RV prune juice and milk of magnesia for the constipation. RP2 stated that we don't do enemas here and that he/she does not like to give enemas. According to RP2, standard procedure is to discontinue all enemas and suppositories. RP3 said that this is something that is usually documented in progress notes but this time it was not. RP3 said that he/she had verbally informed RP2 of the bowel movement. RP2 failed to follow AFH protocol and failed to administer an ordered medication. As a result, RV was transported to the hospital for treatment of constipation. UPDATE 8/14/15: Based on information received during the informal conference, the civil penalty #AFHCP15-07 was withdrawn and the abuse was apportioned to RP2. The withdrawal and LOD went out on 8/14/15.",3,400,Not Substantiated,Substantiated,Neglect +CO16033,525448,AFH,1/28/2016,"On January 28, 2016, the Local Licensing Authority (_x001A_LLA_x001A_) conducted its annual re-licensure inspection. The LLA determined Licensee_x001A_s criminal background clearance had expired November 18, 2015 and he failed to submit his renewal until January 5, 2016. The LLA determined that caregiver TD_x001A_s criminal background clearance expired December 4, 2015 and the renewal was not submitted until January 8, 2016. In addition, the LLA also verified that caregiver JW_x001A_s criminal background clearance expired December 13, 2015 and the renewal was not submitted until January 8, 2016. As of January 28, 2016, the Licensee and caregiver TD_x001A_s criminal background checks had not yet been approved. Between the dates of December 13, 2015 and January 21, 2016 the Licensee as well as two of his caregivers worked in the foster home without an approved criminal background clearance. + + + +During the LLA_x001A_s visit on January 28, 2016 it was discovered that caregiver JW was working unsupervised with no orientation or workbook on file. While reviewing facility documentation, the LLA was unable to locate a screening and assessment for Resident #1 which is required prior to admission. The LLA determined that Resident #1_x001A_s care plan was outdated and had not been properly updated since May 22, 2015. + + + +While reviewing resident medications and facility documentation the LLA observed that Resident #1 and Resident #2_x001A_s medications were set up in unlabeled medication containers and that three different expired medications were found in the same location as the Residents active medications. + + + +Licensee failed to update resident care plans as required, failed to conduct and document a proper screening and assessment prior to admission, failed to ensure all staff had approved and current criminal background clearances and failed to ensure a safe medication system.",2,900,,, +CO12093,525449,AFH,7/5/2012,"On July 2, 2012, the licensor made an unannounced visit to the licensee_x001A_s Adult Foster Home (AFH) in response to a complaint. During the visit the licensor witnessed unqualified caregiver RB providing care to residents alone. RB_x001A_s criminal records check expired May 26, 2012. The licensee failed to provide a safe environment for all residents in the AFH. The licensee_x001A_s failure is a violation of Oregon Administrative Rule. On July 5, 2012, the licensor made an unannounced visit to the licensee_x001A_s AFH to follow up on a complaint that was made on July 2, 2012. During that time, the licensor witnessed unqualified caregiver CO providing care to residents alone. CO_x001A_s criminal records check expired June 27, 2012. The licensee failed to provide a safe environment for all residents in the AFH. The licensee_x001A_s failure is a violation of Oregon Administrative Rule. NOTE: 1/3/13 Final Order by Default completed. Sent to AR person to start aging process.",3,500,,, +CO15168,525474,AFH,8/20/2015,Provider allowed a caregiver to work in the home who did not have an approved background check.,3,250,,, +HB153999,525489,AFH,12/21/2015,"RV uses a urine bag which is emptied daily and changed weekly by an outside provider, although facility staff may change the bag if necessary due to color/odor. On 12/20/15 the facility ran out of bags completely, so staff were unable to change the bag. The facility did not notify the outside agency it needed more bags until 12/23/15, when new bags were dropped off.",1,,,, +CO16050,525505,AFH,3/5/2016,Licensee employed and trained Laird as a caregiver prior to receiving an approved background check. CP sanction $200.00 granted.,3,200,,, +BH153406,525510,AFH,7/4/2015,"On or about July 7, 2015, the Department received a complaint which alleged the Licensee (RP) had failed to develop and implement an appropriate safety plan for Resident #1 (RV). + + + +During the course of the investigation, the Adult Protective Services Specialist (APSS) discovered that RV had a condition which caused confusion and memory loss. Witness #1 (W1) reported that RV had experienced impaired cognition for many years. On or about July 4, 2015, RV was found by law enforcement. Canby Police Report #151038 documented that when officers encountered RV, he/she appeared confused and was not able to supply officers with RV_x001A_s name, where RV lived or the names of any friends or relatives. + + + +Prior to the July 2015 incident, the Department conducted a needs assessment for RV in February 2015. RV_x001A_s Assessment Summary documented that RV required full assistance with awareness, judgment, memory, orientation, wandering and danger to self and others. APSS also reviewed RV_x001A_s care plan which was developed by the facility on March 12, 2015. The facility_x001A_s care plan indicated that RV had a history of wandering and that facility staff should try to redirect RV before he/she left and then contact RV_x001A_s likely destinations. W1 stated to APSS that RV had also wandered away from the facility several months ago. + + + +Licensee failed to implement an adequate care plan to address RV_x001A_s wandering. Licensee_x001A_s failure to provide a safe environment for RV is a violation of resident rights, is considered neglect and constitutes abuse.",3,350,Substantiated,Substantiated,Neglect +CO15234,525526,AFH,11/16/2015,"Preliminary information provided by the Local Office Licensing Authority has established that on November 15, 2015, at approximately 3:00 AM, Licensee was arrested on multiple drug charges in addition to resisting arrest. Licensee is currently lodged in Clackamas County Jail and it is unknown when she will be released. As a result of Licensee_x001A_s arrest, the resident_x001A_s residing in Licensee_x001A_s AFH were left alone for an unknown period of time and did not receive their required care and services. + + + +On November 16, 2015, at approximately 7:30 AM, License_x001A_s neighbor who is also Licensee_x001A_s mother in law and backup provider (_x001A_Witness #1_x001A_) stated she heard crying coming from the AFH. Upon inspection Witness #1 found that one of Licensee_x001A_s resident_x001A_s had fallen while home without a caregiver on duty, and was on the floor crying out for help. Licensee_x001A_s neighbor called 911 and the resident was transferred to the hospital for treatment.",4,,Substantiated,Substantiated,Neglect +HB154055,525526,AFH,11/16/2015,"The licensee failed to provide a safe environment for the residents living in the AFH. Licensee_x001A_s failure to protect her residents from abandonment presented an immediate threat to their health, safety and well-being. Licensee_x001A_s actions are a violation of OARs, is considered neglect and constitutes abuse.",4,,Substantiated,Substantiated,Abandonment +MV152596C,525565,AFH,8/24/2015,"On or about August 24, 2015, the Department received a complaint which alleged the facility had failed to maintain a safe medication administration system. During the course of the investigation, the Adult Protective Services Specialist discovered that Resident #1 (RV) was not administered Medication #1 between the dates of August 15, 2015 through August 21, 2015. Additionally, RV did not received Medication #2 and Medication #3 between the dates of August 14, 2015 through August 19, 2015. Licensee failed to carry out written orders as prescribed and failed to document any missed or refused medications on the back of RV's medication administration record. Licensee's failure to maintain a safe medication system is a violation of Oregon Administrative Rule.",2,,,, +MV164134B,525565,AFH,12/31/2015,"It was reported that on or about December 31, 2015, Licensee failed to provide appropriate care for Resident #2. Licensee applied medication on Resident #2's wounds that he/she did not have a physicians order for. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +CO16111,525606,AFH,4/18/2016,"Local licensing authority requested condition sanction b/c Licensee was not sufficiently staffed to meet care needs of residents. 3 of 4 residents are two-person transfer/hoyer lift (one has diagnosis of quadriplegia). Licensee was able to evacuate all residents under 3 minutes by using proxy for resident with quadriplegia who did not demonstrate physical constraints such as exist for the individual with quadriplegia (proxy got out of bed unassisted and got into a wheelchair without aid, when resident must have two persons to assist out of bed and into wheelchair). Condition was granted requiring increased staffing and verification of proper evacuation drill which meets time frames required by rule. After condition was drafted, APD requested a suspension instead of condition. Condition was not sent. See suspension AFHSUS16-013.",3,,,, +CO16112,525606,AFH,4/18/2016,"Local licensing authority requested suspension due to failure to staff sufficient to meet residents needs and also failure to conduct proper evacuation time. A condition was placed upon the home restricting admissions, requiring increased staffing, and an evacuation drill with appropriate proxy for any resident who did not do fire drill. Also, open APS regarding resident with red area on skin. Resident requires frequent repositioning and Licensee is paid exception to do so.",4,,,, +CO16115,525606,AFH,3/24/2016,Licensee requested and received an Exceptional payment Rate for Resident #1 and Resident #3. Licensee failed to staff the home according to the exceptional rate hours required for these residents. Licensee's AFH license was suspended. Licensee abandoned the licensed premises and landlord terminated the lease. Home is closed.,2,,,, +RD153057,525643,AFH,9/23/2015,"It was reported that on or about September 23, 2015, Licensee failed to appropriate care and services to Resident #1 (RV1). RV1 moved into Licensee's AFH on or about August 30, 2015. Within a few days of arriving, Licensee made the decision that RV1 was a two person assist in showering, toileting and transferring. On September 23, 2015, RV1 returned to Licensee's AFH from a medical visit and there was not a second staff member available to assist RV1 from the car to his/her wheelchair. RV1 sat in the car for approximately 45 minutes waiting for Witness #5 to arrive and assist RV1 from the car into his/her wheelchair. Licensee failed to ensure RV1 received appropriate care and services. Licensee's failure is a violation or OAR, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +MS152693,525677,AFH,9/3/2015,"RV1 was admitted to the adult foster home on August 3, 2015. Witness #5 visited RV1 several times per week with each visit lasting approximately one to four hours. From August 3, 2015 to September 3, 2015 Witness #5 was observed yelling at RV1, threatening to put gloves on RV1's hands, taping RV1's fingers together and smacking RV1's hands to stop him/her from touching his/her nose. In addition, Witness #5 was overheard making demeaning comments to RV1 and Witness #5 was observed preventing adult foster home staff from providing care and sevices to RV1. For approximately one month, the facility allowed Witness #5 to repeatedly enter the adult foster home and verbally and physically abuse RV1. The facility's failure to provide a safe and secure environment and to protect the rights and dignity of RV1 is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO15256,525677,AFH,12/18/2015,The Licensee failed to have a qualified caregiver present and available in the AFH as required by OARS.,2,250,,, +MV164339,525706,AFH,1/17/2016,,2,,Substantiated,Substantiated,Neglect +AL165071A,525862,AFH,3/6/2016,"It was reported that on or about March 06, 2016, Licensee failed to provide a safe medication administration system. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +AL165071B,525862,AFH,3/6/2016,"It was reported that on or about March 06, 2016, Licensee failed to provide a safe medication administration system. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +CO16150,525963,AFH,5/11/2016,"On 5/11/2016 the local licensing authority (LLA) conducted a visit to the AFH and interviewed a bed-bound resident whose care needs required staff assistance for transfer, bathing, toileting and moving her every two hours. The resident stated s/he was unable to get out of bed because it was too hard, but that s/he was otherwise comfortable. The LLA interviewed the caregiver on duty, who stated s/he was unable to meet the residents basic needs alone, but could with an extra caregiver on duty. She stated other caregivers ""come and go to help her as needed."" The caregiver stated she would not be able to evacuate the resident to the initial point of safety in the required three minutes in the event of fire; and stated she could not, alone, get the resident out of bed in under five minutes. The caregiver stated the home was not appropriately staffed for her, with only one caregiver. This information was consistent with prior statements by three other caregivers that they too, would be unable to evacuate all the residents in three minutes.",3,,Substantiated,Substantiated,Neglect +HB151420B,526967,AFH,6/1/2015,"On or about June 1, 2015, APS received an allegation that facility failed to manage pain according to orders. During the course of the investigation, APS determined that the incident occurred but that wrongdoing was inconclusive.",,400,Substantiated,Substantiated, +ES117461B,526991,AFH,7/15/2011,"It was reported that Reported Perpetrator (RP) was not providing appropriate care to Resident #1 (RV1). RP1 was interviewed on July 25, 2011 and stated that RV1's fingernails are trimmed every three weeks to one month. RV1's fingernails were observed to be long with his/her middle fingernail approximately one half inch in length. RP failed to provide appropriate nail care.",1,0,,, +ES153605,526991,AFH,11/4/2015,"RV1 was a resident of Licensee's adult foster home. RV1's care plan dated October 8, 2015 indicated that RV1 does not have behaviors such as wandering or exit seeking yet facility documentation indicates that on the very same day (October 8, 2015) RV1 attempted to elope from the facility and suffered a fall. On October 29, 2015 RV1 left the facility unaccompanied at approximately 2:00 pm. RV1 was located later in the afternoon by a family member that lives nearby. The facility failed to contact police or other emergency responders when it was known that RV1 was wandering unaccompanied. The facility failed to provide a safe and secure environment and failed to provide appropriate care and services to RV1. These failures are violations of the Oregon Administrative Rules.",2,,,, +CO15075,527150,AFH,4/3/2015,"The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on April 1, 2015, attached hereto and incorporated into this notice by reference, substantiated the following:_x001A_ Failure to follow physician orders for Resident #1 (R1). Licensee failed to test CBG two times a day prior to meals as ordered. Insulin was administered 3/25/2015, 3/10/2015, 3/20/2015 and 3/26/2015 when CBG was below 100. This was done after RN gave specific instructions not to administer when below 100. + + + +_x001A_ CRN Madeleine Bucci observed the Medication Administration Record (MAR) not initialed as administered for all 8am medications for R1 on 3/25/2015. CRN arrived at the adult foster home at approximately 9am on 3/25/2015 + + + +_x001A_ Falsified records. Licensee recorded CBG not taken and documented levels different than the monitor readings. The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on March 6, 2015, attached hereto and incorporated into this notice by reference, substantiated the following: + + + +_x001A_ Medications discovered in unlocked cabinet, on the ledge by the dining table, on the kitchen counter by refrigerator and on the shelves in the dining room. Licensee failed to keep medications locked and secured in a central location + + + +_x001A_ MAR not initialed for all residents for all evening/pm medications on 2/27/2015. MAR not initialed on 2/28/2015 for all residents for all medications. The Adult Foster Home Inspection Report and Notice of Violation and Correction, issued on December 17, 2015, attached hereto and incorporated into this notice by reference, substantiated the following: + +_x001A_ MAR not initialed since 12/16/2014 for all residents. Resident #1 (R1) 12/17 2pm medications not initialed as administered. Resident #3 (R3) 12/17 8pm medication already initialed as administered. Resident #5 (R5) 12/17 8am medication not initialed as administered. + + + +_x001A_ Licensee failed to provide access to facility records when requested.",3,450,,, +DA151218,527150,AFH,3/26/2015,"Resident Victim #1 (_x001A_RV1_x001A_) had not been able to talk, eat, or drink for 3 days prior to his/her death. Reported Perpetrator #1 (_x001A_RP1_x001A_) indicated that she knew RV1 was dying. RP1 did not inform RV1_x001A_s doctor of his/her health status change as required. RV1 had requested full resuscitation and had a Physician Orders for Life Sustaining Treatment (_x001A_POLST_x001A_). RP1 failed to comply with RV1_x001A_s POLST and RV1 passed at approximately 1:00 PM on March 26, 2015. RV1 had been deceased for approximately 3 hours when 911 contacted. Witness #1 (W1) stated if 911 had been called right away RV1 might have lived. Licensee_x001A_s failures are a violation of AFH Oregon Administrative Rules (_x001A_OARs_x001A_), are considered neglect and constitute abuse.",4,2500,Substantiated,Substantiated,Neglect +CO15132,527150,AFH,6/29/2015,"Licensee failed to provide RV1 with the necessary care and services BY failed to contact RV1's physician when RV1 health status changed. Additinally Licensee failed to comply with RV1's POLST. Licensee's failures are a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",4,0,,,Neglect +CO15136,527150,AFH,7/8/2015,"Licensee failed to provide RV1 with the necessary care and services BY failed to contact RV1's physician when RV1 health status changed. Additinally Licensee failed to comply with RV1's POLST. Licensee's failures are a violation of AFH OARs, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",4,0,,,Neglect +CO15141,527150,AFH,7/14/2015,"Licensee falsified Resident #1's June 2015, Medication administration records. Wrongdoing on the part of the Licensee was substantiated.",3,500,,, +CO15143,527150,AFH,7/14/2015,"Licensee has failed to protect the health, safety, and well-being of the residents residing in her Adult Foster Home (AFH), resulting in serious harm of mutiple resident. Licensee failure are a violation Of AFH Oregon Administyrative Rules and constitutes abuse!",4,0,,,Neglect +DA151591A,527150,AFH,6/16/2015,"It was reported that on or about June 16, 2015, Licensee failed to protect Resident #1 from inappropriate verbal comments. Licensee told Resident #2 ""I'm just sick of you"", would tell Resident #1 to be quiet, and ridiculed Resident #1, causing him/her to cry. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, and constitutes verbal/emotional abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,Substantiated,Substantiated,Verbal/Mental abuse +DA151591B,527150,AFH,6/16/2015,"It was reported that on or about June 16, 2015, Licensee failed to provide a safe environment for Resident #2. Licensee placed a cotton head-band over Resident #2's head and in his/her mouth to prevent Resident #2 from making whistling noises while breathing. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, and is considered physical abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,Substantiated,Substantiated,Physical Abuse +DA151591C,527150,AFH,6/16/2015,"It was reported that on or about June 16, 2015, Licensee failed to provide appropriate care for Resident #2 (R2). Licensee failed to ensure R2 received timely medical treatment and failed to provide hands on assistance for toileting R2 at night. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,Substantiated,Substantiated,Neglect +HB132204,527494,AFH,1/22/2013,"It was reported that on or about January 22, 2013, Licensee failed to provide a safe secure environment for Resident #1 (RV1). RV1 had a history of eloping from Licensee's Adult Foster Home (AFH) if left unattended. RV1 eloped on February 23, 2012 and October 4, 2012. As a result RV1's care plan was updated on April 12, 2012, to state that RV1 was a ""flight risk"" and ""may open door and leave house"". RV1's care plan stated caregiver was to ""alarm all doors to warn staff when [RV1] has opened doors."" On January 22, 2013, RV1 eloped a third time and was found deceased on January 24, 2013. Licensee's failure to provide a safe environment and failure to follow RV1's care plan is a violation of Oregon Administrative Rules, is considered neglect of care and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",4,2500,,, +NB116150,528356,AFH,1/13/2011,"On or about January 13, 2011, Resident 1 fell and suffered bruising. Licensee failed to notify Resident 1's physician or seek medical treatment",2,0,,, +CO11131,528476,AFH,6/1/2011,"The licensor conducted an inspection of the licensee_x001A_s AFH on June 09, 2011. During the visit the licensor discovered that the smoke alarm located in the hallway was not functional. The licensor also discovered that the smoke alarm in the basement bedroom had been removed from the bracket on the ceiling.",3,450,,, +ES105738,530311,AFH,11/10/2010,"On or about October 2010 and November 2010, Licensee failed to protect residents from misappropriation of resident monies. Licensee obtained money from Residents #2, #3, and #4 and sent it to an individual overseas.",3,750,,,Financial abuse +ES118182A,530311,AFH,10/10/2011,"It was reported that on or about October 10, 2011, Licensee failed to provide appropriate care for Resident #1. Resident #1 was a resident at Licensee's for eleven years. When Resident #1 moved to his/her new Adult Foster Home he/she was found to be undernourished and had dirt caked on his/her body. Licensee's failures are a violation or Oregon Admonistrative Rules. Wrongdoing on the part of the Licensee was substantiated.",0,0,,, +ES118182B,530311,AFH,10/10/2011,"It was reported that on or about October 10, 2011, Licensee failed to use income or assets of an adult for the benefit, support and maintenance of the adult. Licensee was the representative payee for Resident #1's funds and was responsible for receiving and disbursing the funds for Resident #1's benefit. Licensee did not the correct amount of funds that were due to Resident #1. Licensee did not track or account for expenditures for personal items for Resident #1. Licensee's failures are a violation or Oregon Administrative Rules and constitute financial exploitation. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +CO11058,530332,AFH,4/15/2011,,2,250,,, +KF105096A,530332,AFH,8/23/2010,"It was reported that on or about August 23, 2010, Licensee failed to protect Resident #1 (RV1) from verbal abuse. Licensee called RV1 a liar in front of Witness #1 and Witness #2. Licensee's failures are a violation of resident rights and is considered verbal abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Verbal/Mental abuse +KF132223,530332,AFH,1/24/2012,"It was reported that on or about January 24, 2012, Licensee failed to provide appropriate care for Resident #1 and Resident #2. Reported perpetrator #2 (RP2) was left in charge of the facility and was not a qualified caregiver. RP2 wasn't oriented to Resident #1, Resident #2 or the facility. RP2 was not able to locate resident records and failed to provide the required services to ensure the health safety and wellbeing of Resident #1 and Resident #2. Licensee's failures are a violation or Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Neglect +CO15212,531512,AFH,10/5/2015,Firelife Safety Civil Penalties. Mandatory Civil Penalties no smoke alarms.,2,1350,,, +CO11074,533182,AFH,5/6/2011,Licensee pre-initialed MARs.,2,100,,, +MS116628A,533182,AFH,1/24/2011,"On or about January 24, 2011, RP1 called the physician's office wanting to put RV1 on hospice. RP1 did not alert the physician's office that RV1 coud have had a cerebral hemorrhage. RV's family took RV to his/her doctor for examination test. This AFH has since closed therefore no civil penalty will be issued.",3,0,,,Neglect +MS116628B,533182,AFH,1/24/2011,"On or about January 24, 2011 RP1 kept calling RV1's physician's office askig for anti-anxiety medication for RV1. RV1's physician refused to prescribe the medication because RV1 was a fall risk. RP1 was routinely giving RV1 an over the counter sleep aid in the middle of the day that was not part of the physician's orders. This AFH has since closed, therefore no civil penalty was issued.",2,0,,, +MS116628C,533182,AFH,1/24/2011,"On or about January 24, 2011 it was reported that RP1 wouldn't be watching RV1 and RV1 would wander outside. A neighbor of the AFH stood outside with RV1 for a half hour before RP1 finally came outside to look for RV1. RP1 would tell RV1 and RV2 to shut up and sit down. RP1 would tell RV2 that RV2 was being ""bad"". This AFH has since closed therefore no civil penalty was issued.",3,0,,,Neglect +MS116628D,533182,AFH,1/24/2011,"RV1's beginning weight at the AFH was 150 lbs on October 28, 2010. On February 9, 2011, RV's weight was 139 lbs. There were no fresh vegetables or fruit at the AFH. RV1, RV2, and RV3 were not provided with proper nourishment.",2,0,,, +MS116628E,533182,AFH,1/24/2011,"On May 5, 2011 APS Investigator discovered RV2 was being given over the counter medications routinely that were not authorized by RV2's physician. RP also wanted anit-anxiety medication prescribed for RV1 and RV2. RV1 and RV2's physician would not prescribe the medication. This AFH has since closed therefore no civil penalty was issued.",2,0,,,Neglect +RB117425,533380,AFH,7/8/2011,"On the morning of July 8, 2011 RV1, RV2, RV3, and RV4 did not receive their medications. There were no adverse affects on the residents for not receiving their medications.",2,0,,, +ES118690,534537,AFH,12/12/2011,Resident #1 (RV1) reported that Reported Perpetrator #1 (RP1) is loud and yells at him/her. RV1 does not like being yelled at. Multiple witness statements indicate that RP1 yelled at RV1. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rule.,2,0,,, +ES132824,534537,AFH,3/6/2013,"RV had medical orders for oxygen to be used as directed. RP1 acknowledged knowing of the oxygen order, but did not follow the orders or use the oxygen in a safe manner. RP1 had no records of oxygen being used or oxygen saturation being measured. In addition, RP1 failed to use necessary compression hose on RV's legs, with the result that RV's legs and abdomen became grossly distended and painful. RP1 took away RV's commode resulting in RV soiling h/hself. RV was unable to walk or get up from broken recliner, and had no way to call for help. RV developed an infection and had to be moved to a higher level of care.",3,,,,Neglect +RB121792,534896,AFH,11/25/2012,"On or about November 25, 2012, it was alleged that Reported Perpetrator (RP) failed to assure Reported Victim's (RV) resident rights. RV exhibits aggressive behaviors at the table during dinner toward caregiver's and residents. In response to RV's behavior RP has RV sit with a TV tray facing the wall away from the dining table. The licensee failed to assure RV's resident rights. The failure is a violation of Oregon Administrative Rules.",2,0,,, +TM129283,535799,AFH,2/2/2012,"It was reported that on or about February 2, 2012, Licensee failed to properly administer Resident #1's (RV1) medications. On February 6, 2012 Witness #5 (W5) called Reported perpetrator #2 (RP2) and gave verbal orders to change RV1's medication. On February 8, 2012, during a medical appointment, it was found that RP2 did not follow W5's instructions to change RV1's medication. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO11122,537618,AFH,7/22/2011,,3,0,,, +HB120577A,537618,AFH,7/20/2012,"On or about July 20, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) from inappropriate verbal comments. Reported Perpetrator #2 (RP2) was witnessed calling RV1 a ""bitch"" by Witness #1 (W1) and Witness #6 (W6). RP2 was also witness calling RV1 ""fucking bitch"" by Witness #7 (W7). Witness #4 (W4) acknowledges that RP2 and RV1 have a difficult relationship, and W4 advises RP2 that RP2 cannot let RV1 ""get to h/her"". It was determined that the licensee failed to protect RV1 from inappropriate verbal comments. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HB120577B,537618,AFH,7/20/2012,"On or about July 20, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim #1 (RV1) from rough treatment. Reported Perpetrator #2 (RP2) was seen by Witness #1 (W1) pushing RV1 back by putting h/her hand on RV1's upper chest. RP2 was also seen by W1 taking RV1's forearm and spinning RV1 quickly and forcefully around. The licensee failed to protect RV1 from rough treatment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO11123,537626,AFH,7/22/2011,,3,0,,, +CO11133,537626,AFH,7/22/2011,,3,0,,, +HB117754,537626,AFH,8/17/2011,"On or about August 17, 2011, Reported Perpetrator #2 (RP2) administered Resident #2_x001A_s (RV2) medication to Resident #1 (RV1). As a result of the medication error, that night around 3:00am RV1 became dizzy, weak and required assistance in and out of bed. Due to the medication error, RV1 was not able to or urinate for at least 24 hours. The licensee failed to provide a safe medication administration system which resulted in unreasonable discomfort to RV1. The failure is a violation or Oregon Administrative Rule and constitutes abuse. NOTE: email sent to AR to begin the aging process 1/10/13.",3,400,,,Neglect +RS120468,539200,AFH,7/7/2012,"It was reported that on or about July 7, 2012, Licensee failed to protect Resident #1 (RV1) from theft of his/her medications. Licensee received a shipment of medications on July 6, 2012. Licensee put the medication in his/her room under a towel instead of in the locking medication cabinet. On July 7, 2012, Licensee found that RV1's narcotic medications were missing from in his/her room where he/she had placed them under a towel. Licensee's failures are a violation of Oregon Administrative Rules (OARs), is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +BH150946,540013,AFH,4/1/2015,"RV has a history of calling for help at night. RV has been encouraged to call for assistance, but recommend RV only call for urgent needs during the night. Facility staff feel sleep deprived due to RV's multiple night time requests. However, RV's care plan does not address night time needs, requests or interventions.",2,,,, +BH133466B,540018,AFH,6/6/2013,"On or about June 6, 2013, it was alleged that Reported Perpetrator (RP) failed to intervene when Reported Victim's (RV) condition changed. RV was making coffee when RV spilled boiling water on him/herself. Witness #3 (W3) asked RV if he/she wanted 911 to be called. RV verbally refused medical treatment. W3 poured cold water on the burn and put a burn gel on RV. RV later went to RV's physician and it was found that RV sustained second and third degree burns on RV's knee caps due to the spill. The licensee failed to notify emergency personnel after RV's condition changed. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS147019A,540075,AFH,5/9/2014,"It was reported that on or about May 9, 2014, Licensee failed to provide appropriate care to Resident #1 (RV1), Resident #2 (RV2) and Resident #3 (RV3). Reported Perpetrator #2 (RP2) failed to follow resident care plans for toileting resulting in skin redness and irritation. RV1 was found to have a skin rash and blisteres. Licensee's failures are a violation of Oregon Administrative Rules. RP2's failures are considered neglect and constitute abuse. Wrongdoing on the Licensee and RP2 has been substantated.",2,,Not Substantiated,Substantiated,Neglect +CO15211,540146,AFH,10/5/2015,Provider and caregiver have expired background checks and were working alone on date of inspection. Meds were not locked.,3,450,,, +CO11124,541438,AFH,7/22/2011,,3,0,,, +CO14174,543673,AFH,8/27/2014,"Caregiver did not have background check prior to working in the home. Caregiver also had not completed caregiver workbook, and by extension, orientation to the home. Licensee received 2 violations at this inspection. 517C also noted, and included, copy of violation for expired background checks on 3 people on 8/12/13. A review of OLRO files indicates that this was never sent to OLRO for a mandatory civil penalty.",3,250,,, +RB118709A,544929,AFH,12/12/2011,"Resident #1 (RV1) admitted to Reported Perpetrator #1's adult foster home (AFH) from a nursing facility on December 12, 2011. The narcotics record from the nursing facility showed 140 narcotic pain pills accompanied RV1 to the AFH. RV1's narcotic pain medications were not counted when RV1 arrived at the facility. On December 13, 2011, 60 narcotic pain pills were discovered missing. Multiple staff members had access to the medication cabinet. The facility failed to have a medication system that prevented theft of medications. The failure is a violation of resident rights, is considered neglect and constitutes abuse. During the investigation, it was also discovered that criminal history checks for two facility caregivers had expired.",2,0,,,Neglect +CO14076,544929,AFH,4/21/2014,Unqual cg left alone with residents,3,250,,, +RS151459,544929,AFH,6/1/2015,"On or about June 2, 2015, Adult Protective Services (APS) received a complaint that the facility failed to maintain an adequate medication system. During the course of the investigation, APS substantiated the following: RV had a prescribed narcotic pain medication and a muscle relaxer. RV moved from RP's home on June 1, 2015, and a narcotic medication count was done that day; 5 pills were unaccounted for. RV's muscle relaxer medication had run out and RV had gone without it that morning. RV's muscle relaxer medication was called into the pharmacy to be picked up. The facility failed to provide a safe medication administration system and this failure is a violation of Oregon Administrative Rule.",2,,,, +BH121435A,546031,AFH,10/9/2012,"On or about October 9, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from verbal mistreatment. RP made inappropriate and derogatory remarks toward RV which resulted in RV being fearful of RP. It was determined that the licensee failed to protect RV from verbal abuse. The failures are a violation of resident rights, and constitute abuse.",2,0,,,Verbal/Mental abuse +ES148236A,547096,AFH,8/21/2014,"It was reported that on or about August 21, 2014, Licensee failed to dispense medication and prepare breakfast for resident's timely. Licensee sleeps in until well after 8:00AM on days when he/she is on duty for breakfast and morning medication care. Licensee failures are a violation of Adult Foster Home Oregon Administrative Rule, are considered neglect of care and constitute abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +RB117121,547302,AFH,5/2/2011,"On or about May 3, 2011 it was reported that RP1 left medication patches in the RV's room for the RV to self administer. There were 105 unopened medication patches removed from RV's belongings.",2,0,,, +GP121456,547302,AFH,10/25/2012,"On or about October 25, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate service to Reported Victim (RV). RV was admitted to the licensee's Adult Foster Home (AFH) on or about October 15, 2012, without any skin wounds. Between 10/15/2012 and 10/27/2012 RV developed a sore on h/her left foot and RV's right lower interior leg. RV also developed blisters on h/her left heel and skin breakdown on RV's coccyx. The licenseen failed to provide appropriate care to RV. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +GP147115A,547302,AFH,1/1/2014,"On or about May 19, 2014, the Department received a complaint that alleged the Licensee had failed to provide appropriate care and services to Resident #1 at Licensee_x001A_s adult foster home (AFH). Resident #1 (RV1) required use of a Hoyer lift to transfer himself/herself out of bed. RV1 reported that RP (Licensee) did not use the Hoyer due to her shoulder injury and except for Witness #1 (W1), the other caregivers did not know how to operate it. RV1 stated that because of this, he/she spent most of his/her time in bed. + + + +Additionally, RV1 and Resident #3 (RV3) reported that Witness #5 (W5) was the nighttime caregiver. RP and Witness #5 acknowledged that W5 did not provide personal care. RP and W5 further acknowledged that if a resident needed assistance with his/her absorbent briefs or cleansing, W5 would call W1 to the AFH. W1 lived approximately 10 minutes from the facility. In cases where RV1 could not get the caregiver_x001A_s attention, RV1 stated that he/she tried not to have a bowel movement because he/she did not want to be soiled and have to wait until W1 arrived for his/her next shift. + + + +Resident #1, Resident #2 (RV2), Resident #3, Witness #3 (W3) and W5 also reported that there were no call bells in resident rooms so they had to bang on the wall or yell for assistance. + + + +Licensee failed to ensure appropriate staffing to meet the needs of all residents, failed to provide appropriate care and services and failed to provide a safe environment, + + + +Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse. RV1, RV2, RV3, W3, W4 and W6 reported that caregivers at Licensee_x001A_s AFH ensured that all residents were in bed with the lights out by 8pm. RV2 further reported that the residents must also keep their doors closed. + + + +Licensee failed to allow residents the right to choose at what time they went to their rooms in the evening, failed to allow residents to choose when they turn off the lights in their bedrooms, failed to allow residents to choose whether or not they close their bedroom doors, failed to provide a home-like environment and failed to treat all residents as adults with respect and dignity. Licensee_x001A_s failure is a violation of resident rights, is considered involuntary seclusion and constitutes abuse.",3,1100,,,Neglect +GP147115B,547302,AFH,1/1/2014,"On or about May 19, 2014, the Department received a complaint which alleged the facility had failed to protect residents from inappropriate verbal interactions. During the course of the investigation, multiple witnesses reported that they had heard the Licensee and facility caregivers yell at residents. Licensee failed to provide a home-like atmosphere; failed to assure that each resident was treated as an adult with respect and dignity; and failed to provide a safe environment. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",2,,,, +GP148218,547302,AFH,7/18/2014,"On or around August 21, 2014, Adult Protective Services (APS) received a complaint alleging the facility failed to provide timely medical treatment. During the course of the investigation, APS determined that RV had an unwitnessed fall which resulted in injury. RV reported to RP and staff that RV had pain and his/her elbow was ""not right"". RV's skin tear was treated with an adhesive bandage and RP placed a call to RV's doctor and left a voicemail that was not returned. RP did not take RV for medical attention following the fall. After RV moved to another facility, RV was taken to Urgent Care due to pain, swelling, and bruising in the area of the right elbow. Medical staff advised RV that his/her elbow was broken and RV should have been seen sooner. No documentation or the unwitnessed fall could be located; APS was not notified. Facility's failure to assure timely medical treatment resulted in RV's pain and suffering continuing. This failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +CO15214,547302,AFH,10/6/2015,,3,700,,, +GP152910B,547302,AFH,8/1/2015,"It was reported that on or about August 1, 2015, Licensee failed to provide appropriate care to Resident #1. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +MF105766,549456,AFH,12/3/2010,"On or about December 3, 2010, it was reported that Resident #1 (RV1) had not been receiving his/her medication #1 for behaviors as ordered by RV1's medical professional. The last dose of medication #1 was given to RV1 on December 1, 2011. RV1 went without his/her medication #1 on December 2, 2010 and December 3, 2010. RV1's behaviors escalated as a result of facility's failure to administer medication as ordered. Wrongdoing on the part of the Licensee was substantiated.",2,700,,,Neglect +MS118772A,549456,AFH,12/26/2011,"On December 26, 2011, Resident #1 (RV1) experienced a fall at approximately 1:30am. Witness #3 (W3) heard RV1 yelling for help and notified Reported Perpetrator #2 (RP2). RP2 was unable to assist RV1 to his/her bed, due to RV1 being combative. RP2 felt RV1 was not injured and gave RV1 a pillow and covered RV1 with a blanket. At approximately 9:30am the next morning, RP2 asked W3 to help getting RV1 back into bed. W3 is not a qualified caregiver. RP2 contacted Witness #2 (W2). When W2 arrived at the AFH, W2 requested RP2 call for an ambulance. Emergency services transported RV1 to a medical facility. Documentation from the medical facility noted that RV1 had multiple pressure marks on his/her body, breakdown of muscle due to prolonged down time, and lack of water in RV1_x001A_s system. The facility failed to provide appropriate care and services resulting in physical harm, unreasonable discomfort, and loss of dignity. The failure is a violation of resident rights, is considered neglect, and constitutes abuse.",3,450,Substantiated,Substantiated,Neglect +MS118772B,549456,AFH,12/26/2011,Resident #1 (RV1) was admitted to licensee's adult foster home (AFH) in October 2011. RV1's Medication Administration Record (MAR) for the month of October 2011 shows that RV1 had been given Medication #1. Medication #1 was not transferred to the November 2011 or December 2011's MARs. RV1 was not dispensed Medication #1 in November or December 2011. There was no order to discontinue administration of Medication #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS118772C,549456,AFH,12/26/2011,"Resident #1's (RV1) Medication Administration Record (MAR) for December 2011 indicates that RV1 was taking multiple medications. RV1 had a short hospital stay at the end of December 2011. On December 29, 2011, RV1 was discharged back to licensee's adult foster home with orders to discontinue Medication #1, #2, #3, #4, and #5. RV1's MAR entries for December 30, 2011 show that RV1 was administered Medication #1, #2, and #3. Facility failed to follow medication orders. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO12053,549456,AFH,2/6/2012,Allowing a caregiver with an expired criminal records check to work in the home alone and for admitting a resident beyond the licensed capacity.,3,400,,, +CO12070,549456,AFH,7/24/2012,condition to compel submission of financial records,3,0,,, +CO14107,549456,AFH,6/4/2014,Licensee's background check expired and caregiver #1's (SD) background check expired.,3,500,,, +CO14170,549464,AFH,8/21/2014,"Licensee had unqualified caregiver in the home, unsupervised, providing care to the residents. Caregiver did not have first aid/cpr card, nor had they completed the prepatory study guide/workbook.",3,250,,, +CO12111,549493,AFH,9/13/2012,Unqualified caregivers; multiple med system issues; over capacity; care plans not completed;,3,1050,,, +CO12118,549493,AFH,10/29/2012,,3,0,,, +KF121191,549493,AFH,10/1/2012,"On or about October 1, 2012, it was alleged that Reported Perpetrator (RP) failed to prevent theft of Reported Victim's (RV) medication. Several of RV's medications were missing. RV1 was witnessed in the past getting into the locked medication cabinet. RP has moved the key to the medication cabinet multiple times. It was not determined exactly how many of RV's medication were missing. The licensee failed to provide a system that prevented theft of RV's medication. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF135200,549493,AFH,11/24/2013,"On or about November 26, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to protect Reported Victim (RV) from theft of medications. During a workshift Witness #1 (W1) discovered several of RV's pain pills missing. W1 conducted a count of the pain medication and found that 10 1/2 pain pills were missing. RP1 knew Reported Perpetrator #2 (RP2) from alcoholics anonymous and Narcotics Anonymous. RP1 employed RP2 and gave RP2 unsupervised access to medications. RP1 approached Reported Perpetrator #2 (RP2) about the missing pain medication. RP2 acknowledged that he/she took the pain medication for RP2's own personal use. RP2 was terminated from employment. The licensee failed to protect RV from theft of medication. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +KF135456,549493,AFH,12/20/2013,"On or about December 23, 2013, the Department received a complaint that alleged Licensee had worn inappropriate clothing in front of residents at the AFH. During the course of the investigation, Resident #1 (RV1) and Resident #2 (RV2) reported that Licensee had worn sheer clothing in the AFH on more than one occasion. RV1 further stated that he/she had looked away when this occurred. Licensee (RP2) acknowledged that she had worn lightweight clothing at the AFH. It was determined that Licensee failed to provide an environment which assured residents were treated with dignity and respect. Licensee_x001A_s failure is a violation of Oregon Administrative Rule.",2,,,, +CO15031,549493,AFH,2/13/2015,Suspension hand delivered on 2/13/15. Licensee submitted a hand written notice of voluntary closure of her AFH on 2/27/15. The AFH is now closed.,4,0,,,Abandonment +KF105040B,549514,AFH,8/16/2010,"On or about August 16, 2010, Licensee spoke to Resident 1 in a deragatory manner.",2,100,,,Verbal/Mental abuse +KF134195,549514,AFH,8/13/2013,"It was reported that on or about August 13, 2013, Licensee failed to provide appropriate care to Resident #1. Resident #1 developed a pressure sore within 18 days of living in Licensee's Adult Foster Home (AFH). Reported Perpetrator #1 (RP1) and Reported Perpetrator #2 (RP2) would not respond to Resident #1's requests for assistance in general, and would not respond to Resident #1's request for assistance to use the bathroom. RP1 and RP2 repeatedly failed to assist Resident #1 to the bathroom or onto the commode and would tell Resident #1 to go in his/her depends. Licensee's failures are a violation or AFH Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +KF148816,549514,AFH,9/26/2014,"During a facility investigation conducted on or about October 7, 2014, the investigator discovered the Licensee had failed to provide t appropriate care to Resident Victim #1 (RV1). RV1 had been transferred with a Hoyer Lift due to his/her medical condition. RV1_x001A_s Hoyer Lift was determined to be unsafe and not in working condition. Licensee had a second working Hoyer Lift in the home but chose not to use the working Hoyer Lift because it was located in another room in the facility. On September 19, 2014, instead of using a Hoyer Lift to transfer RV1, Licensee decided to manually transfer RV1 resulting in a fall. Licensee reported RV1 had no signs or symptoms of pain on September 19, 2014. RV1_x001A_s Medication Administration Records (MARs) indicated Licensee gave RV1 narcotic pain medication on September 19th, September 20th, and September 21st of 2014. The reasons listed for giving narcotic pain medication read _x001A_still have pain_x001A_ and _x001A_not resolved_x001A_. RV1 did not receive any other pain medication during the month of September 2014. On September 22, 2014, Licensee sought medical help for RV1 and hospital notes indicated RV1 suffered from a femur fracture. Licensee_x001A_s failure is a violation of residents_x001A_ rights, is considered neglect and constitutes abuse.",3,400,,,Neglect +KF150582C,549514,AFH,2/26/2015,"It was reported that on or about February 26, 2015, Licensee failed to protect Resident #1 from inappropriate verbal comments, and emotional abuse. Resident #1 complained of being put down by Licensee as well as feeling fearful of Licensee and feeling humiliated by the way he/she had been treated. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Verbal/Mental abuse +KF120923,549659,AFH,8/28/2012,"Resident #1 (RV1) kept his/her wallet in RV1's dresser drawer. On or about August 12, 2012, RV1 asked the licensee to retrieve money from his/her wallet and it was identified that money was missing from RV1's wallet. On or about August 28, 2012, additional funds were found to be missing from RV1's wallet after Reported Perpetrator #2 (RP2) had been in RV1's room. RP2 acknowledged that he/she had taken money from RV1's wallet on two occasions. RP2 was terminated and agreed to have $180.00 deducted from his/her last paycheck. Facility failed to provide a safe environment. Licensee's failure is a violation of Oregon Administrative Rule.",3,0,Not Substantiated,Substantiated,Financial abuse +CO12050,550350,AFH,4/27/2012,"A Home visit was conducted at licensee_x001A_s Adult Foster Home (AFH) on April 27, 2012. Upon arrival, Department staff found that Licensee had left a sub-caregiver whose criminal record check had been denied, alone with the residents. Licensee_x001A_s failure is a violation of Oregon Administrative Rules.",3,250,,, +CO12113,550350,AFH,8/30/2012,,2,0,,, +EN149111A,550350,AFH,10/20/2014,"Resident #1_x001A_s (RV) care plan dated 5/11/2014 notes that RV is not oriented to time and place. RV is incontinent of bowel and bladder. RV will sit in him/her chair and urinate until chair and clothing are soaked unless you insist he/she use the restroom more than once during the day. At night RV never gets up so RV and the bed are usually wet in the morning. Witness #3 (W3) assessed RV and noted that RV was weak, couldn_x001A_t walk and was not eating. RV was admitted to the hospital. Upon admission Witness #5 (W5) assessed RV and observed yeast infections under his/her pectoral folds, folds of his/her abdomen, in the groin and genital area. RV also had a massive urinary tract infection. W5 stated that he/she believes the cleanliness and yeast infections were _x001A_totally avoidable._x001A_ Nurses notes from the hospital dated 10/06/2014 through 10/18/2014: RV_x001A_s skin integrity is poor and RV is very thin, abrasion at left calf, yeast at pectorals, groin and perineum and skin breakdown at coccyx ted ruddy color to bilateral heels and coccyx area, no open areas just areas of reddening patient in the hospital due to a UTI and weakness. RV also has yeast infections below the pectorals and perineum area. + +The licensee failed to care plan for RV_x001A_s needs as required and failed to provide appropriate care to RV. The failures are a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,400,,,Neglect +EN153744,550350,AFH,8/18/2015,"It was reported that on o about 08/18/2015, Licensee failed to maintain an adequate and appropriate medication administration system. Wrongdoing on the part of the Licensee was substantiated.",2,,,, +EN133710B,550350,AFH,7/3/2013,"It was reported that on or about July 3, 2013, Licensee failed to protect Resident #1 from inappropriate verbal comments. Reported Perpetrator #2 (RP2) has raised her voice at resident's in the past, and there was at least one occasion where RP2 got into an argument with Resident #1 and raised his/her voice. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Verbal/Mental abuse +CO13044,551072,AFH,4/17/2013,Failed to submit financial documentation requested by the local office.,2,0,,, +AL133468A,551072,AFH,3/12/2013,"On March 12, 2013, Resident #1 experienced a fall which resulted in ""bruising"" to his/her forehead and lacerations on his/her right elbow and right lower leg. Witness #3 and Witness #5 did not report the fall with injury to Resident #1's physician, family member or case manager. Licensee acknowledged that Resident #1 has a ""continuous history"" of falling and falling from his/her bed is ""not an unusual event"". Resident #1's care plan dated February 22, 2013 does not address frequent falls or address interventions to prevent falls. Licensee failed to intervene when Resident #1 sustained injuries and failed to adequately care plan surrounding falls. Licensee's failures are a violation of resident rights, are considered neglect and constitute abuse.",3,,,,Neglect +AL133468D,551072,AFH,3/12/2013,"Resident #1 admitted to a new facility on April 10, 2013. Witness #6, Witness #7 and Witness #8 reported that Resident #1 arrived from Licensee's adult foster home unclean and with his/her clothes and slippers smelling of urine. Resident #1 was showered with a white wash cloth at the new facility. Afterwards, the cloth being used was described by Witness #8 as ""totally brown"" and by Witness #6 and Witness #7 as ""stained brown"". Licensee stated that Resident #1 was ""difficult to shower"" and did not get showered ""as much as s/he needs"". Licensee failed to provide adequate assistance with hygiene. The failure is a violation of Oregon Administrative Rule.",2,,,, +AL133468C,551072,AFH,3/12/2013,"On April 2, 2013 at 3:00pm, a medical professional visited Resident #1 at licensee's adult foster home (AFH). Resident #1 was observed sitting on the edge of Resident #1's bed with a lunch tray in his/her lap. Resident #1 was sleeping with his/her head resting in a plate of food which had two small pieces of sandwich on it. Licensee acknowledged that ""it has been fairly common for [Resident #1] to fall asleep with h/h head in h/h plate of food"". Resident #1's care plan, dated February 22, 2013, indicates in the Feeding and Nutrition section that Resident #1 ""needs close monitoring and/or to be hand fed."" Licensee failed to follow Resident #1's care plan which placed the resident at high risk of aspirating his/her food. Licensee's failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +AL133468B,551072,AFH,3/12/2013,Resident #1 has a medical condition which causes swelling of his/her feet. Resident #1 has a history of positioning him/herself in bed with his/her feet hanging down. This position increases edema to Resident #1's legs and feet. Resident #1 is care planned to wear TED hose at night if he/she will not lie down. The care plan does not include daytime interventions to prevent or limit Resident #1's chronic leg and foot swelling while he/she is in bed with his/her feet hanging down. Licensee failed to adequately address Resident #1's care needs. The failure is a violation of Oregon Administrative Rule.,2,,,, +CO11025A,551536,AFH,1/20/2011,Licensee failure to ensure caregivers had been oriented to home and had completed the Department's preparatory workbook,3,500,,, +CO11025B,551536,AFH,1/20/2011,,3,0,,, +TM121848,551536,AFH,12/9/2012,"It was reported that on or about December 9, 2012, Licensee failed to provide appropriate care to Resident #1. Reported Perpetrator #2 (RP2) instructed Witness #3 (W3) to ask Witness #2 (W2) to perform an enema on Resident #1. RP2 stated if a resident has not had a bowel movement in 5 days staff will try suppositories and enemas. There was no documentation that Licensee or staff had contacted Resident #1's physician for instruction on how to precede if Resident #1 had not had a bowel movement after 5 days and Licensee did not have a physician_x001A_s order for the use of suppositories and enemas. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +TM118807,551536,AFH,12/1/2011,"It was reported that on or about December 1, 2011, Licensee failed to provide appropriate care to Resident #1 and Resident #2. Resident #1 was seen in the emergency room on December 27, 2012, and Resident #2 was seen in the emergency room on December 26, 2012. Both resident arrived at the emergency room in wet incontinence wear. Licensee's failures are a violation or Adult Foster Home Oregon Administrative Rule. Wrongdoing on the part of the Licensee was substantiated.",1,,,, +BR118251A,554035,AFH,8/15/2011,"It was reported that on or about August 15, 2011, Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee placed a compression sleeve on RV1's arm without a physician's order. RV1 experienced pain, developed skin discoloration and blistering. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BR118251C,554035,AFH,8/15/2011,"It was reported that on or about August 15, 2011, Licensee failed to provide appropriate care and services for Resident #1 (RV1). It was found that RV1 was wearing the same dirty clothes for multiple days. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BR118251E,554035,AFH,8/15/2011,"It was reported that on or about August 15, 2011, Licensee failed to follow physician's orders for Resident #1 (RV1). RV1 had a physician's order for medications that were not administered as ordered. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BR135010,554035,AFH,7/18/2013,"It was reported that on or about July 18, 2013, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee (RP2) left Reported Perpetrator #3 (RP3) in charges of the Adult Foster Home (AFH) from June 20, 2013 through June 24, 2013. Upon RP2's return to the AFH On June 24, 2013, it was discovered that RV1 was missing medications. Licensee's failures are a violation of Oregon Administrative Rules. RP3's failures are considered financial exploitation and constitute abuse.",3,,Not Substantiated,Substantiated,Financial abuse +HB147144,554191,AFH,5/20/2014,"On or about April 9, 2014, Licensee observed _x001A_blisters_x001A_ on Resident #1_x001A_s (RV1) bottom. Licensee reported that she had communicated with RV1_x001A_s healthcare professional about the _x001A_blisters_x001A_ but the medical practitioner _x001A_ignored_x001A_ Licensee so the Licensee thought it was fine. Licensee was unable to produce any notes of her conversation with RV1_x001A_s healthcare professional. + + + +On or about April 29, 2014, Licensee observed that RV1_x001A_s arm was swollen and a blister had developed on RV1_x001A_s arm. Licensee stated that she called RV1_x001A_s healthcare professional. A Kaiser Foundation Telephone Encounter document dated April 29, 2014, indicated that the Licensee was advised to _x001A_protect the area and pad or wrap the arms to keep the skin safe._x001A_ Licensee stated that she checked the site and changed the bandage daily; however, Licensee reported that she did not document her actions. + + + +On or about May 13, 2014, the blister _x001A_exploded_x001A_ and Licensee called RV1_x001A_s healthcare professional who advised the Licensee to keep the area clean. Licensee stated that RV1_x001A_s medical professional did not elaborate on how to clean the affected area. Licensee wanted a medical professional to assess RV1_x001A_s limb but the agency that reviews and assesses RV1_x001A_s medical needs did not come to the AFH. Licensee reported that she did not have any means to transport RV1 to a medical facility. + + + +On or about May 15, 2014, Witness #1 (W1) visited RV1 at the AFH. W1 observed that RV1_x001A_s hand on the affected arm had swollen up to two or three times the normal size and the skin looked translucent. W1 spoke to Licensee about RV1_x001A_s condition and Licensee responded that she was taking care of it. In an interview with W1 on May 20, 2014, he/she indicated that RV1 had described that he/she had experienced pain and itchiness in his/her arm for over two weeks and that he/she could not move the affected arm. + + + +On or about May 20, 2014, Department staff visited RV1 and observed that RV1_x001A_s right forearm was swollen to approximately twice the size of RV1_x001A_s left arm and that his/her wrist was indiscernible from the arm due to the swelling. Documentation from RV1_x001A_s emergency room visit on May 20, 2014, indicated that RV1 had an acute skin ulcer approximately 4cm x 6cm on his/her right upper extremity. The same document described two decubital ulcers on RV1_x001A_s right buttock. It was also noted that RV1_x001A_s _x001A_arm edema_x001A_ was likely _x001A_secondary to the circumferential bandage_x001A_ used and that keeping the _x001A_arm elevated and the dressing loose will treat the edema._x001A_ + + + +Additionally, during the course of the investigation, it was determined that RV1 cannot get in and out of bed without assistance. The AFH has three levels, resident rooms are on the bottom floor and the caregiver sleeps on the top floor. RV1 did not have a call button to alert staff. RV1 stated that he/she wears incontinent garments and that RV1 had to wait until a caregiver came to assist him/her with peri care. W1 had spoken to Licensee about RV1 not having access to a call button and Licensee responded that RV1 probably wouldn_x001A_t use one anyway. Licensee confirmed that W1 had asked her about RV1 not having a call button. Licensee stated that she was unsure if RV1 would know how to use a call button so Licensee did not provide one. + + + +Licensee failed to request clarification of medical advice so she could fully understand and provide appropriate care for RV1. Licensee failed to document all conversations with RV1_x001A_s healthcare professionals. Licensee failed to document all care provided to RV1_x001A_s affected arm. Licensee failed to provide or arrange transportation for RV1 so he/she could receive necessary medical care. Licensee failed to assess and intervene in a timely manner when RV1 experienced a change in condition. Licensee failed to provide RV1 with means to alert Licensee or caregiver in the event RV1 required assistance with care needs or in the event of an emergency. Licensee_x001A_s failures are a violation of residents_x001A_ rights, is considered neglect, and constitutes abuse.",3,400,,,Neglect +BH132501,555792,AFH,11/19/2012,"It was reported that on or about November 19, 2012, Licensee failed to provide a safe environment for Resident #1. Resident #1 was picked up for a medical appointment by medical transport, when being dropped off at the Adult Foster Home (AFH) after the appointment no one was there to answer the door. Local law enforcement was called and showed up just after the Licensee. Reported perpetrator #2 (RP2) was at the AFH but was unable to hear the door bell because he/she was in the shower with ear plugs in. Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO15119,555958,AFH,6/19/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +CO15123,555958,AFH,6/22/2015,Final Fitness Determination was denied. A contested case hearing was held and the denial was upheld. No longer meets the qualification requirements of a Licensee. Conditions on all four homes were issued and will be followed by non-renewal/revocations as appropriate.,3,0,,, +PT150404,557905,AFH,2/12/2015,"It was reported that on or about February 12, 2015, Licensee failed to protect Resident #1 from restraint. Licensee used a bed sheet to tie Resident #1 to the toilet. Licensee's failures are a violation of Oregon Administrative Rules. Wrongdoing on the part of the Licensee was substantiated.",2,,,,Neglect +BR132298B,560065,AFH,11/5/2012,"It was reported that on or about November 5, 2012, Licensee failed to provide a safe and secure environment for Resident #1 (RV1). Licensee failed to provide appropriate skin care for RV1's skin irritations. On November 5, 2012, RV1 was sent to the hospital and hospital staff found areas of ""grade 2 breakdown"" of RV1 skin. Licensee's failures are a violation of Oregon Administrative Rules is considered neglect and constitutes abuse.",2,,,,Neglect +BR132298A,560065,AFH,11/5/2012,"It was reported that on or about November 5, 2012, Licensee failed to provide appropriate care to Resident #1 (RV1). On November 3, 2012, RV1 was found on the bathroom floor after he/she had fallen off the commode. Reported perpetrator #2 (RP2) was unable to assist RV1 off the floor. Licensee had to assisted RV1 off the floor by pulling him/her up by one arm. On November 3, 2012, RV1 was given an over the counter medication to help with pain and stiffness. On November 5, 2012, an ambulance was called for RV1 because he/she was having shoulder pain and had limited range of motion due to an injury of the shoulder. RV1 was transferred to the hospital and was given steroid injections as a result. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,400,,, +BR132239,560065,AFH,8/12/2012,"It was reported that on or about August 12, 2012, Licensee failed to provide appropriate care for Resident #1 (RV1). On August 12, 2012, the menu was not followed. Two of the three meals served were not from the menu. A half of a subway sandwich was offered to RV1 in exchange for a meal and RV1 did not want to eat the subway sandwich,. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",1,,,, +ES118818A,564711,AFH,11/1/2011,"It was reported that on or about November 1, 2011, Licensee failed to provide a safe environment for Resident #1 (RV1). Licensee sprayed RV1 with water, RV1 then went to his/her room and later stated that he/she felt belittled when Licensee sprayed him/her. Licensee's actions are a violation of resident rights and constitutes mental abuse.",2,0,,,Verbal/Mental abuse +MV145794A,565270,AFH,1/9/2014,"On or around 1/15/14, APS received an allegation that facility failed to provide a safe medication system. A resident had a prescription for Tramadol and PRN Hydrocodone/acetaminophen. The Medication Administration Record (MAR) indicates the resident received Tramadol and Hydrocodone/Acetaminophen two times daily. Diagnostic tests indicated that the resident did not have Tramadol or Hydrocodone/Acetaminophen in his/her system. The resident was not administered his/her prescribed medication. The facility failed to administer medication as ordered. This failure is a violation of resident rights, is considered neglect, and constitutes abuse.",2,,,,Neglect +CO14254,565270,AFH,12/26/2014,Licensee dismantled smoke detector downstairs.,3,250,,, +RD146787,565858,AFH,4/15/2014,"On or about April 25, 2014, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim (RV). RP conducted the screening and assessment of RV over the phone prior to admitting RV. RV's care plan dated 4/3/2014 notes RV required full assist with bathing, transferring and dressing. RV does not walk and is a full assist with toileting. RV's screening and assessment dated 4/2/2014 notes that RV uses a wheelchair and hospital bed. RP does not have the ability to transfer RV by RP's self. RP and RV entered into a verbal agreement that RV would stay in bed and would receive bed baths instead of transferring RV to the shower and RV would wear briefs instead of transferring RV to a commode/toilet. The licensee failed to provide appropriate care to RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +BO151862,565858,AFH,6/13/2015,"On or about June 13, 2015, Licensee had a struggle with Resident #1 (_x001A_RV1_x001A_) over medications that were improperly dispensed. Licensee dispensed RV1_x001A_s medications, RV1 was holding the medication in his/her hand and noticed that he/she did not get one of his/her ordered medications. When RV1 told Licensee that he/she did not get one of his/her medications, Licensee disagreed with RV1, grabbed RV1_x001A_s wrist with one hand and tried to pry open RV1_x001A_s hand with her other hand to confirm whether or not RV1 got the medication. Licensee caused discoloration on RV1_x001A_s hand and wrist as a result of grabbing RV1_x001A_s wrist and attempting to pry RV1_x001A_s hand open. Witness #1 was called to the AFH by RV1 and confirmed that Licensee did not provide RV1 with all of his/her ordered medications. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Physical Abuse +BO151863,565858,AFH,6/18/2015,"On or about June 18, 2015, Licensee failed to ensure Resident #1 (_x001A_RV1_x001A_) had been administered his/her ordered medications. RV1 was discharged from the hospital on June 16, 2015. The discharge paper work included 5 medication orders that Licensee did not have filled and did not have in the AFH, resulting in RV1 not receiving his/her ordered medications. Additionally, Licensee withheld an ordered medication when RV1 was going in for a _x001A_blood cleaning procedure_x001A_ and Licensee did not have orders to withhold the ordered medication. In addition, Licensee failed to ensure all ordered medications were listed on RV1_x001A_s medication administration record (MAR), and failed to ensure the missed medication were documented on the MAR as required. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +BO154068A,565858,AFH,11/13/2015,Licensee failed to administer medication according to physician orders. Wrongdoing on the part of Licensee was substantiated.,3,,Substantiated,Not Substantiated,Neglect +BO154068B,565858,AFH,11/13/2015,Licensee failed to administer medication according to physician orders. Wrongdoing on the part of Licensee was substantiated.,3,,Substantiated,Substantiated,Neglect +CO16021,565858,AFH,1/27/2016,LLA requested sanction action to close home and place condition on home until final closure. Provider signed voluntarily closure notice prior to completion of state action.,4,,,, +CO16060,565858,AFH,3/9/2016,"LLA submitted sanction requests for condition and home closure. Prior to completion of sanctions, provider gave notice of voluntary closure. Home will close 4/10/16",3,,,, +BO164977,565858,AFH,2/16/2016,On 11/15/15 RV was given a prescription for an antidepressant to be administered once a day in the morning. On 2/12/16 RV's physician changed the administration time to evening. Between 2/12/15 and 2/22/15 the facility continued to administer the medication in the morning.,2,,,, +CO11135,566211,AFH,7/21/2011,"The licensor conducted an inspection of the licensee_x001A_s AFH on July 21, 2011. During that inspection the licensor discovered a smoke alarm was not functional in an occupant_x001A_s bedroom.",3,200,,, +JG132839B,566211,AFH,3/12/2013,"On March 13, 2013, Resident #1 was found unresponsive by Reported Perpetrator #2 (RP2) at approximately 7:45am. RP2 checked Resident #1 for a pulse and respirations and found neither. RP2 reported that he/she _x001A_placed my hand on [Resident #1]_x001A_s chest and s/he felt warm._x001A_ RP2 did not call emergency services or Resident #1_x001A_s medical professional. RP2 continued to _x001A_check_x001A_ on RV every 15 minutes and _x001A_found no change in his/her condition._x001A_ + + + +At 8:30am RP2 called Licensee to obtain further instructions. + + + +At 9am, RP2 called Witness #6 but was not able to reach him/her but spoke with Witness #5 instead. Witness #5 did not know if Resident #1 had pre-arranged any funeral services. It was after 9am when RP2 _x001A_called two funeral homes [directly] to see if there was a pre-arrangement for funeral services and was told no by both. I called the first funeral home to come and get [Resident #1]._x001A_ + + + +RP2 stated that _x001A_it is not protocol to call RP1 immediately and normally I would call the funeral home._x001A_ RP1 confirmed that the facility_x001A_s protocol is to call the family and then the funeral home when a death has occurred. Both Licensee and RP2 reported that they thought Resident #1 had a DNR directive. The licensee was unable to produce a copy of a DNR. + + + +During the course of the investigation, it was determined that Resident #1 had completed a Physician_x001A_s Orders for Life-Sustaining Treatment (POLST). The POLST was dated September 5, 2012. Under Section A of the POLST that addresses Cardiopulmonary Resuscitation (CPR) in the event the patient has no pulse and/or is not breathing, the _x001A_Attempt Resuscitation/CPR_x001A_ box is marked. + + + +The facility failed to notify emergency personnel of the death or suspected death of a resident, failed to obtain a copy of the POLST prior to Resident #1_x001A_s admission and failed to maintain a copy of the POLST in the resident_x001A_s record. These failures placed Resident #1 at potential risk of serious harm, violated resident rights, are considered neglect and constitute abuse.",3,400,Substantiated,Substantiated,Neglect +JG153749A,566211,AFH,8/30/2015,"RV moved into RP1's AFH on 8/30/2015, and was receiving home health/hospice care. RV was incontinent of bowel and bladder, was susceptible to skin breakdown, and was at risk of falling. RV's care plan required two hour checks during the daytime and ""frequent"" checks at night. At about 10:00 p.m. on 8/30/2015 RP1 checked on RV, but did not check again until 7:00 a.m. the following day, when RP1 discovered RV had fallen on the floor. It was unknown how long RV had lain on the floor. RP1 checked RV and found no bruising or abrasions, and RV did not complain of pain. On 09/01/2015 RV complained of hip and ankle pain and was given some pain medication. On 09/03/2015 a DHS transition coordinator visited and expressed concern about RV's pain. RV was offered but declined pain medication. On 09/05/2015 the home health/hospice nurse visited. The nurse and found two bruises on RV's leg, and the leg was very cold. The nurse also found a bruise on top of RV's leg and one by RV's feet, and thought RV could be experiencing an arterial blood clot s/he did not think was caused by the fall. The nurse believed the pain was cause by the clot, not the fall, but recommended hospital care to rule out or determine blood clot. RV was taken by ambulance to the hospital, to determine possible blood clot. RV passed away on 09/08/2015.",3,600,Substantiated,Substantiated,Neglect +JG153749B,566211,AFH,8/30/2015,"RV entered RP1's facility on 8/30/2015. RV was receiving home health/hospice care. RV was in bed the majority of the time. RV's family stated RV was at risk of falling, and requested bed rails, but RP1 did not obtain or conduct a risk assessment for falls, nor obtain a doctor's order for bed rails. A short bed rail which did not run the full length of the bed. was used on RV's bed from the time RV entered the facility. The other side of the bed was placed against the wall.",2,,,Substantiated, +HB129920,566760,AFH,4/27/2012,"On or about April 27, 2012, it was alleged that Reported Perpetrator (RP) failed to properly use a physical restraint for Reported Victim (RV). An doctor's order by RV's physician gives authorization for a gait belt. The order states that the gait belt may be wrapped around one arm of the chair and stipulated that the use of the gait belt should be reevaluated in one month. It was determined through interviews and observations that the gait belt was tied around the arm of the chair rather then wrapped as the physician ordered. The licensee did not reevaluate the use of the gait belt as the physician directed. The licensee failed to assure resident rights. The failures are a violation of Oregon Administrative Rules.",2,0,,, +BA146407,567342,AFH,3/4/2014,"Resident #2 (RV2) was admitted to the licensee's (RP1) adult foster home (AFH) in October, 2013. RP1 received RV2's Individual Service Plan (ISP) and Behavior Support Plan (BSP) and was informed of previous sexual behaviors displayed by RV2. RV2's BSP stated staff must maintain personal boundaries with RV2, including not permitting RV2 to follow one into private areas, such as the bathroom, other's bedrooms and not allowing RV2 to stand too close, touching one in inappropriate ways, or fixating on certain parts of the body. + + + +On March 4, 2014, RV2 entered RV1's bedroom and displayed inappropriate sexual behaviors, including attempting to get on top of RV1. RV1 expressed fear and stated he/she was afraid it might happen again. + + + +The licensee failed to properly plan for RV2's care and failed to follow the Behavioral Support Plan. The failures are a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,400,,,Neglect +CO12062,567581,AFH,6/12/2012,"An annual re-licensure visit was conducted at licensee_x001A_s adult foster home (AFH) on June 12, 2012. During the visit, the licensor determined that the smoke alarm in the common area of the AFH had been removed. The licensee failed to provide a safe environment. The licensee_x001A_s failure is a violation of Oregon Administrative Rules.",3,250,,, +RB120970,568977,AFH,8/31/2012,"On or about August 31, 2012, it was alleged that Reported Perpetrator (RP) failed to assure Reported Victim #1 (RV1) and Reported Victim #2's (RV2) resident rights. The licensee left RV1 and RV2 in a van for at least 45 minutes while RP worked inside a Sunday school room. RV1 began to cry out for help. RP went to assist RV1 and RP became upset with RV1. RP hollered at RV1 and gave RV1 a verbal move out notice. It was determined the licensee failed to assure resident rights for RV1 and RV2. The failures are a violation of Oregon Administrative Rules.",2,0,,, +RB116383,569157,AFH,2/17/2011,"On or about February 17, 2011, it was reported that the Licensee faile to provide a safe environment for Resident #1 (RV1). RV1 was bitten on five separate occasions by Licensee's dog, three of which RV1's skin was broken. It was found that wrongdoing on the part of the Licensee was substantiated.",2,0,,,Physical Abuse +ES132469,569405,AFH,10/1/2012,"Resident #1 (RV1) had an order for Medication #1 to be given PRN (as needed) for pain. RV1's Medication Administration Record (MAR) for September 2011 indicated that RV1 had been administered Medication #1 three times per day from September 1, 2011 through September 20, 2011. Evidence of Medication #1 typically remains in the body for approximately 72 hours. On September 9, 2011, an urinalysis was ordered by RV1's medical professional. The results failed to show Medication #1 was present in RV1's system. The licensee failed to maintain a safe medication administration system. Licensee's failure is a violation of Oregon Administrative Rule.",1,0,,, +ES134175,569405,AFH,5/15/2013,"In approximately April or May of 2013, there were two occurrences of when Resident #1 discovered his/her cash missing. Resident #1 stated that he/she keeps a close eye on his/her wallet. The first loss was in the amount of $40.00 and the second loss was for $50.00. Resident #1 told the licensee (RP1) that he/she would not tell anyone about the missing cash because RP1 had reimbursed him/her. When interviewed, RP1 stated that she had replaced $20.00, not $90.00 and that it happened only one time. + + + +Later Resident #1 identified that he/she was missing a fly tying kit. The kit was purchased for him/her by Witness #2 (W2) for approximately $50.00. + + + +During the course of the investigation, it was discovered that Reported Perpetrator #2 (RP2) had worked in licensee_x001A_s adult foster home (AFH). RP2 stated that he/she assisted people to bed, cleaned and cooked meals at the AFH. Witness #4 (W4) reported that he/she understood that RP2 could not pass a background check. Witness #3 (W3) stated during his/her interview that RP1 had RP2 working in the facility on the weekends because RP1 knew that the State of Oregon didn_x001A_t inspect facilities on the weekend. + + + +RP1 stated during her interview that RP2 did not work in the AFH but would come to the AFH and prepare breakfast and lunch [in approximately December of 2012] and that was it. RP1 further commented that any witnesses that said RP2 was working in RP1_x001A_s AFH were lying. RP1 also asserted that RP2 did not use the AFH as his/her address. + + + +Department records related to RP2 were reviewed by the investigator. A record dated April 5, 2012 and signed by RP2 listed the address of the AFH as RP2_x001A_s home address and the facility_x001A_s land line as RP2_x001A_s phone number. A second record dated October 24, 2012 and signed by RP2 listed the address of the AFH as RP2_x001A_s address and indicated _x001A_same_x001A_ in the space for his/her mailing address. A third record dated April 12, 2013 and signed by RP2 includes a statement by RP2 that _x001A_I live in a trailer next to [RP1]. I work 1 day for exchange of rent._x001A_ The investigator also verified judicial information that indicated RP2 had been convicted of a crime that would potentially disqualify RP2 from obtaining an approved background check. + + + +The theft of Resident #1_x001A_s assets is considered financial exploitation and constitutes abuse. The investigation failed to determine the party or parties responsible for the missing property. Therefore the finding of abuse was apportioned to an unidentified individual(s). + + + +Licensee failed to have approved criminal record checks for all subject individuals and failed to exercise reasonable precautions against any condition(s) that could threaten the health, safety or welfare of residents at licensee_x001A_s AFH. Licensee_x001A_s failures are violations of Oregon Administrative Rule.",3,300,Not Substantiated,Substantiated,Financial abuse +ES133812A,569405,AFH,7/13/2013,Resident #1 was advised by licensee that Resident #1's room was needed for another resident. Licensee's family member went into Resident #1's bedroom and packed Resident #1's belongings and moved them to a different bedroom. Resident was then told that he/she had to leave licensee's adult foster home (AFH). Licensee acknowledged that he/she told Resident #1's family to take Resident #1 away. Licensee also stated to Resident #1's family that he/she would not accept Resident #1 back to the AFH. Licensee failed to issue a mandatory written notice to Resident #1 prior to moving Resident #1 to another room and failed to issue a written notice to Resident#1 prior to moving Resident #1 out of licensee's AFH. These failures are violations of Oregon Administrative Rule.,2,,,, +ES133812B,569405,AFH,7/13/2013,Resident #1 was told to leave licensee's adult foster home (AFH) without prior notice. Resident #1 requested his/her medications to take to his/her new residence. Licensee only released enough medication for one day at a time. Resident #1's family member had to return to licensee's AFH each day for additional medication until the licensee released all of Resident #1's remaining medications. Facility failed to respect the rights and preferences of Resident #1. The failure is a violation of Oregon Administrative Rule.,2,,,, +ES134516,569405,AFH,8/30/2012,"Resident #1 (RV1) possessed a 19_x001A_ flat screen television while residing at licensee_x001A_s adult foster home. The television was not being used and was kept in RV1_x001A_s bedroom closet. During a telephone conversation with Witness #1 (W1), RV1 mentioned that an unidentified individual had been in his/her bedroom and walked away with the television. When W1 next visited the AFH, he/she verified that the television was missing from RV1_x001A_s closet. Witness #2 (W2) understood that the loss occurred a few weeks prior to December 8, 2012. + + + +Licensee disclosed that Reported Perpetrator #2 (RP2) had been living in the garage at the time the television went missing. Licensee acknowledged that she was aware that RP2 had friends over for _x001A_slumber parties_x001A_ and that RP2 and his/her friends had access to the home through the garage. Witness #3 (W3) reported that RP2 would go into RV1_x001A_s room and also use the shower that was allocated for resident use. + + + +W1 and W3 reported that the licensee had told each of them separately that a friend of RP2 admitted to taking the television. The licensee did not name the individual who took RV1_x001A_s property. + + + +Licensee acknowledged that as a mandatory reporter it was her responsibility to report the theft to the Department and to law enforcement but did neither. The incident was not documented in facility records. + + + +Responsibility for the theft which is considered financial exploitation was apportioned to the unidentified individual. Licensee paid W1 $200 as reimbursement for the loss of RV1_x001A_s assets. + + + +Licensee failed to exercise reasonable precautions against any condition(s) that could threaten the health, safety or welfare of residents at licensee_x001A_s AFH. Licensee_x001A_s failures are violations of Oregon Administrative Rule.",3,200,Not Substantiated,Substantiated,Financial abuse +CO14198,569405,AFH,10/6/2014,OLRO prepared a notice of non-renewal based upon multiple instances of APS and for noncompliance with a final order of the Dept (not paying a civil penalty). The condition was written to accompany the non-renewal so that no new residents would be admitted until the non-renewal is either final or overturned.,3,0,,, +CO14235,569405,AFH,11/4/2014,Licensee does not live in the home and does not have an exception for primary caregiver rule. Denied local licensing authority's civil penalty request and instead added this to the non-renewal sanction as an additional count. Local office then informed us that provider voluntarily surrendered license and provided 30 day notice to residents. Home to close 1/7/15. Asked local office to send copies of the close notice.,3,,,, +CO15104,570031,AFH,6/1/2015,Licensee allowed a substitute caregiver to work in the home since at least July 2014 without an approved background check. Licensee then had caregiver act as resident manager in the home without application or approval from LLA. Caregiver worked alone on at least one occasion.,3,450,,, +BH133018,577473,AFH,12/15/2012,"On or about December 15, 2012, it was alleged that Reported Perpetrator (RP) failed to protect Reported Victim (RV) from inappropriate verbal comments. RP stated to RV ""I am the man of the house, I am the King, and you need to do what I tell you"". RP would occasionally hit h/her hands against a door and yell at RV. As a result RV was afraid of RP. The licensee failed to protect RV from verbal mistreatment. The failure is a violation of resident rights and constitutes abuse.",2,,,,Verbal/Mental abuse +RD117370,578521,AFH,5/10/2011,"On or about October 2010 through May 2011, Licensee failed to protect Resident 1 from financial exploitation. Caregiver 1 refilled a narcotic pain medication that had previously been prescribed to Resident 1 but had been discontinued on or about September 2010. Caregiver 1 received 12 refills totaling 800 tablets.",3,200,Not Substantiated,Substantiated,Financial abuse +BH120268,580048,AFH,6/11/2012,"It was reported that on or about June 11, 2012, Licensee failed to treat Resident #1 (RV1) with respect and dignity. Licensee becomes impatient and angry with RV1 when he she requests showers that Licensee does not think RV1 needs. Licensee's failures are a violation of Oregon Administrative Rules (OARs). Wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BF103431,580303,AFH,1/28/2010,"It was reported on or about February 08, 2010, that the Licensee failed to intervene when Resident #1's (RV1) condition changed. After RV1 passed the Licensee failed to contact the 911 prior to contacting RV1's spouse and physician. Interviews concluded that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +BH105141,580303,AFH,8/31/2010,"On or about 8/1/10, it was reported that licensee failed to have medication on hand for Resident #1 (RV) per doctors orders. Licensee failed to provide RV #1 medications as ordered by physician. RV did not sustain a negative outcome.",1,0,,, +BH133889,580303,AFH,12/31/2012,"On or about December 31, 2012, it was alleged that the Reported Perpetrator (RP) failed to provide a safe envrironment for Reported Victim (RV). RV was admitted to the Adult Foster Home (AFH) on 12/26/2012. On 12/31/2012 Witness #2 (W2) was dispatched to a welfare check and discovered RV. (W2) observed RV to be lost and unable to identify where he/she lived. W2 observed RV to be cold as the temperature was in the mid to low 30's. RV was transferred back to RP's by paramedics. RV did not sustain any injury. RV's screening and assessment dated 12/18/2012 indicated that RV wanders at night to look for his/her spouse. During the time of the incident RV's care plan had not been completed. RP stated that RV must have left the facility when RP turned off the door alarm to bring in groceries. RV was gone approximately 30-40 minutes. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rule.",2,,,, +BH149221,580303,AFH,11/12/2014,"It was reported that on or about November 12, 2014, that Licensee failed to provide appropriate care and services to Resident #1 (RV1). Licensee failed to administed RV1 narcotic pain medication as ordered and failed to ensure RV1 had been changed and turned adequately. Licensee's failures are a violation of Adult Foster Home Oregon Administrative Rules, is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee has been substantiated.",3,400,,,Neglect +OT151603,580774,AFH,6/8/2015,"It was reported that on or about June 8, 2015, Licensee failed to provide appropriate care to Resident #1 (RV1). RV1 sat on the back porch of the Adult Foster Home in the sun for an undetermined amount of time, resulting in RV1 sustaining a sun burn. Licensee's failures are a violation of OARs is considered neglect and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",2,,Substantiated,Substantiated,Neglect +HB117019,583141,AFH,5/19/2011,"Resident #1 (RV1) had a prescription for a mood stabilizing medication that was to be taken four times a day. Interviews and observations concluded that RV1 did not receive RV1's medications at 10pm on March 21, 2011 and at 5pm on March 23, 2011. The Licensee failed to administer all doses of an ordered medication.",2,0,,, +HB118212,584537,AFH,10/10/2011,"It was reported that on or about October 10, 2011, Licensee failed to provide a safe environment resulting in missing narcotic pain medication. Licensee kept Resident medications in a black metal filing cabinet located on the second floor of the Adult Foster Home. The lock on the filing cabintet could easily be picked and unlocked with various objects and keys. On September 13, 2011, Licensee found that Resident #1's (RV1) entire card of narcotic pain medication, containing 29 pills was missing. On September 15, 2011, Licensee found that Resident #2 (RV2) was also missing 27 narcotic pain pills. Licensee's failures are a violation of resident rights and constitue financial exploitation. Wrongdoing on the part of the Licensee was substantiated.",2,0,,,Financial abuse +MF116306A,585104,AFH,2/9/2011,"On or about February 9, 2011, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #1 (RV1) and Reported Victim #2 (RV2). It was determined that appropriate care was not provided to RV1 and RV2 by RP.",2,0,,, +MS116669,585104,AFH,4/5/2011,"On or about April 5, 2011 it was reported the Licensee failed to maintain an adequate medication system. An unidentified pill was found loose in RV1's medication bin, and one half of an unidentified pill was found loose in RV2's medication bin. Several blister packs had been broken and then taped over with scotch tape.",2,0,,, +NW105242,585872,AFH,9/1/2010,"On September 1, 2010, Resident #1 (RV1) was observed to be lying in a bed that was positioned with one side of the bed against a wall. RV1's covers were pulled up to his/her neck and tucked tightly into the mattress along the full length of the bed. According to RV1's care plan, RV1 uses a sleeping bag without a zipper to keep him/her warm. The top blanket is not to be tucked into the mattress in order to avoid any restriction to RV1. By having the top blanket pulled up to RV1's neck and tucked into the mattress, the Licensee failed to follow the care plan which resulted in the top blanket being a restraint.",2,200,Not Substantiated,Substantiated,Restraints +NW148303,585872,AFH,4/14/2014,Prepared NOFs separately (see file): Allegation A - Failed to provide appropriate care and services; Allegation B - Failed to provide a safe medication administration system; Allegation C - Facility failed to intervene when Resident #1 experienced a change in condition.,3,,,,Neglect +NW148922,585872,AFH,6/12/2014,"It was reported that on or about June 12, 2014, Licensee failed to protect the property of Resident #1 (RV1).Reported Perpetrator #1 (RP1) expressed to multiple parties that she was going to keep RV1's television and book case because RV1 owed RP1 for his/her glasses. RV1's property was at RP1's on June 12, 2014, and on June 13, 2014, the property was no longer at RP1's. Licensee's failure is a violation of Oregon Administrative Rules, is considered financial exploitation and constitutes abuse. Wrongdoing on the part of the Licensee was substantiated.",3,,,,Financial abuse +NW148943A,585872,AFH,10/6/2014,"On or about October 7, 2014, Adult Protective Services (APS) received a complaint that the facility failed to protect RV from yelling, swearing, name-calling, and being mocked. During the course of the investigation, APS substantiated that RP1, RP2, and RP3 yelled at RV. RP2 and RP3 mocked RV. RP3 discussed disciplining RV with a 2 by 4. RP1 used profanity at, and around, RV. RP1 used names and derogatory remarks about RV such as ""Asshole RV"", lying, and stating that ""old people are deaf."" RP1, RP2, and RP3's actions are verbal/emotional abuse. The facility failed to protect RV from yelling, swearing, name-calling, and being mocked. The facility's failure is a violation of resident rights and constitutes verbal/emotional abuse.",4,,Substantiated,Substantiated,Verbal/Mental abuse +NW148943B,585872,AFH,10/6/2014,"On or about October 7, 2014, Adult Protective Services (APS) received an allegation that the facility failed to provide care to a resident (RV). During the course of the investigation, APS substantiated the following: RP1 had limited physical ability to provide personal care such as showering, transferring, and changing RV. RP2 did not provide some aspects of personal care to RV. RV was left in soiled briefs for extended times. RP1 failed to ensure that RV had adequate incontinent products and failed to ensure that RV was adequately cleaned following bowel movements, and failed to provide showers every week. RP1 failed to provide care by leaving RV's bed wet, a wheelchair pad with feces covered over with a chux pad and RV sat back down in chair, left RV at dining table naked except for a towel for 3 hours, and allowed RV to be taken to a doctor's appointment with dried feces on legs and peri area. RV had injuries from a fall occuring on or about 10/17/14 which were not tended to. RP1 failed to provide a caregiver after 8pm who could adequately assist with RV's night time care needs. RV was not receiving enough to eat in the facility. RP1 and RP2 failed to provide care and this failure is a violation of resident's rights, is considered neglect, and constitutes abuse.",3,,Substantiated,Substantiated,Neglect +NW148943C,585872,AFH,10/6/2014,"On or about October 7, 2014, Adult Protective Services (APS) received a complaint that RP1 prevented RV from having access to freely move about the home. During the course of the investigation, APS determined that RP1 and RP2 would get annoywed when RV came out of RV's room. RP1 and RP3 could get mad at RV when RV got up at night. RV's wheelchair would be left out in the hallway, where RV was unable to get to it, or placed in a position that would make it difficult for RV to use or get to. RP2 would not get RV his/her wheelchair. RP1 put a cane in a sliding door of RV's room so that RV could not open the door to exit. A chair was in front of RV's door to keep RV in the room. RP1 and RP2 prevented RV from having access to freely move about the home, which is a violation of resident rights, is considered involuntary seclusion, and constitutes abuse.",3,,Substantiated,Substantiated,Involuntary Seclusion +NW148943D,585872,AFH,10/6/2014,"On or about Oct. 7, 2014, Adult Protective Services (APS) received a complaint that RP1 failed to follow the service plan by removing RV's art supplies. RV was a remarkable and talented artist. RV's care plan notes that RV can be motivated by art and caregivers are to keep art supplies at hand for RV. RP1 and RP3 removed RV's art supplies and placed them where RV was unable to either reach the supplies or use them. RP1's and RP3's actions are a violation of resident's rights and a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +MV134399,586334,AFH,9/11/2013,"On or about September 11, 2013, it was alleged that Reported Perpetrator #1 (RP1) failed to provide appropriate care to Reported Victim (RV). RV's care plan dated 4/12/13 under Mobility/Transfers states that RV ""gets around by h/h self"". It was documented in RV's progress notes that RV fell twice during the week of 6/21/13. Paramedics were contacted on the first fall. RV sustained sustained scrapes up h/h arm and bruising on h/h back. The July progress notes state that RV was having difficulty walking. August progress notes indicate that RV was ""full assist with everything"". RV fell the week of 9/7/13 and got feces everywhere. On 9/6/13 RV was observed at the kitchen table wearing h/h undergarment with just a towel over h/h. Reported Perpetrator #2 (RP2) stated that jeans were too hard to put on RV so h/she didn't put any pants on RV. RV was transferred to another facility on 9/7/13. Upon arrival at the new facility RV was observed to have multiple pressure sores on h/h bottom. RP1 and RP2 was unaware of skin issues on RV's bottom. The licensee failed to provide appropiate care to RV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV147258,586334,AFH,5/22/2014,"On or about May 23, 2014, Adult Protective Services received a complaint that the facility failed to treat RV's rash properly, resulting in discomfort and bleeding. During the course of the investigation, APS determined that RV had a rash in late April and had been applying an expired bacterial skin cream which had no effect. RV did not have a physician's order for the over-the-counter cream. RV's rash bled and the bleeding was discovered on RV's bed sheet on 4/27/14. RP1's staff were aware that RV used the cream and made an appointment to get medical attention for the rash on 5/2/14. The prescription cream was used to treat the skin rash. Facility's failure to dispose of discontinued medication and failure to provide appropriate skin care is a violation of resident rights, is considered neglect and constitutes abuse.",2,,,,Neglect +MV117470,586441,AFH,7/14/2011,"On or about July 15, 2011, it was reported that the Licensee failed to provide appropriate care to Resident #1 (RV1). Licensee failed to have the needed equipment for RV1's required testing and failed to ensure RV1 received proper amounts of medication. It was found that wrongdoing on the part of the Licensee was substantiated.",2,0,,, +CO11129,586441,AFH,7/28/2011,"The licensor conducted a monitoring visit of the licensee_x001A_s Adult Foster Home (AFH) on July 28, 2011, in response to a complaint that was made on July 25, 2011. During the visit the licensee admitted that the licensee had allowed Caregiver #1 to work in the AFH without a Criminal Records Check. The licensor discovered that Caregiver #2 had also been working in the AFH without a Criminal Records Check. Caregiver #2_x001A_s criminal record check approval was not received until August 23, 2011. Signed delegation records indicate insulin was being administered to Resident #1 and Resident #2 by Caregiver #3. This was confirmed by the provider. Caregiver #3 was not delegated to administer insulin to Resident #1 or Resident #2.",3,750,,, +CO12043,586441,AFH,2/24/2012,10/2/13-FOD completed and sent on 10/10/13,3,0,,, +CO13069,586441,AFH,5/23/2013,"On May 23, 2013, the licensor conducted a renewal visit at the licensee_x001A_s Adult Foster Home (AFH). During the visit the licensor inspected caregiver GS bedroom. Upon inspection the licensor observed a required smoke detector had been removed from the bedroom. The licensee failed to maintain all required smoke detectors. The licensee_x001A_s conduct constituted a failure to provide a safe environment and is a violation of Oregon Administrative Rules. UPDATE 7/26/13: FOD sent this date, emailed AR to begin aging process.",3,250,,, +CO11132,587407,AFH,6/17/2011,"The licensor conducted an inspection of the licensee_x001A_s AFH on June 17, 2011. During the visit the licensor discovered that the hardwired smoke alarm in a resident bedroom was not functional.",3,200,,, +MM116397,588363,AFH,2/18/2011,"Reported Victim #1 (RV1) was admitted to the facility with signs of confusion and wandering. Facility progress notes indicated that RV1 began to show aggression toward staff on January 12, 2011. On January 29, 2011 RV1 struck RV2 with a writing tablet. RV1 was ordered to undergo a gero-psych evaluation on January 29, 2011 but the facility failed to follow up on the order and obtain the evaluation. On February 19, 2011 RV1 took RV2's walker and refused to let go. The facility failed to have a care plan or appropriate interventions in place.",2,0,,, +DA134197B,591276,AFH,7/26/2013,"Resident #1 (RV1) went to the emergency department. RV1 reported that when RV1 returned to licensee's adult foster home (AFH), licensee said, ""You blew it! You blew it! You knew I could take care of you!"" RV1 stated to Witness #1 (W1) that he/she was ""tired of being screamed at every time I have an accident."" Licensee failed to treat RV1 with dignity and respect. The failure is a violation of Oregon Administrative Rule.",2,,,, +MM135487,591276,AFH,12/20/2013,"Resident #1 reported that licensee told him/her that licensee may not be able to keep licensee's adult foster home open due to financial struggles. Resident #1 reported that he/she did not want to be out on the street so he/she gave licensee money in excess of his/her usual monthly payments. Resident #2 believed that he/she would be homeless if licensee continued to have financial hardships. Resident #2 also gave money to licensee at licensee's request. A report obtained from Polk County Sheriff's Office indicates that Resident #2 gave licensee over $16,000 during a period of several months. Licensee failed to protect residents from financial loss. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",4,,,,Financial abuse +MV135447,591276,AFH,12/11/2013,"On or about December 13, 2013, the Department received a complaint that alleged the Licensee (RP1) had failed to provide appropriate care and services for Resident #1 (RV). The investigation concluded that Licensee failed to maintain a safe medication administration system, failed to intervene when RV experienced a change in condition and failed to assure timely medical treatment. Licensee_x001A_s failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,,,,Neglect +NB116149,592100,AFH,1/18/2011,"On or about January 5, 2011, Licensee failed to protect Resident 1 from theft of medications. Caregiver 1 took 20 narcotic pain medication tablets belonging to Resident 1 from Licensee's medication cabinet. This medication had been discontinued on January 4, 2011 however Licensee failed to dispose of the medication. Licensee failed to administer a medication to Resident 1 per physician orders, failed to have a physician order to allow Resident 1 to self-medicate and failed to keep a medication locked.",2,0,,, +NB120036,592100,AFH,5/12/2012,"On or about May 12, 2012, it was alleged that Reported Perpetrator #1 (RP1) failed to provide a safe environment for Reported Victim #1 (RV1), Reported Victim #2 (RV2), Reported Victim #3 (RV3) and Reported Victim #4 (RV4). It was determined through interviews that Witness #1 (W1) came to facility to speak to Reported Perpetrator #2 (RP2). RP2 and W1 began to have a verbal disagreement. W1 then left the facility, RP2 followed W1 and left the RV1, RV2, RV3 and RV4 unattended without a qualified caregiver in the Adult Foster Home (AFH). The RV's were left alone for 15-30 minutes before RP1 arrived back at the facility. The licensee failed to provide a safe environment. The failure is a violation of Oregon Administrative Rule.",2,0,,, +NB121959B,592100,AFH,12/23/2012,"On or about December 23, 2012, it was alleged that Reported Perpetrator (RP) failed to provide appropriate care to Reported Victim #2 (RV2). RV2 requires assistance with mobility and transfers per RV2's assessment. RV2 has a history of falls and is a known fall risk. RP has not provided RV2 with the ability to call for assistance if RV2 falls in h/her bedroom. The licensee failed to provide appropriate care to RV2. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,0,,,Neglect +NB133511,592100,AFH,6/14/2013,"On or about June 14, 2013, it was alleged that Reported Perpetrator (RP) failed to provide a safe environment for Reported Victim (RV). It was determined that RV was prescribed an as needed medication (prn). RP's Medication Administration Record for the month of May 2013 demonstrates that RV was being administered prn medication on a routine basis. RV's condition was not reflected on RV's care plan. RV's care plan was not updated as residents condition changed. The licensee failed to provide a safe environment for RV. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO13007,592761,AFH,12/13/2012,"On December 13, 2012, the licensor conducted a renewal inspection at the licensee_x001A_s adult foster home (AFH). During the inspection the licensor tested a smoke alarm in a bedroom in the licensee_x001A_s quarters and discovered that it was not functional. Upon further investigation the licensor found that the batteries were removed from the smoke alarm. The licensee failed to provide a safe environment. The licensee_x001A_s failure to provide a safe environment is a violation of Oregon Administrative Rules.",3,250,,, +CO14012,592969,AFH,1/2/2014,"A licensing visit conducted by the local licensing authority on January 2, 2014, discovered Licensee documenting evacuation drills dated April 13, 2013, July 15, 2013, October 3, 2013 and January 1, 2014. Licensee acknowledged the drills were not documented at the time they were conducted. Licensee explained she was filling out the forms based on the caregivers notes however the licensee was unable to produce the notes she referenced. Licensee failed to document evacuation drills at the time they were conducted. Licensee acknowledged creation of evacuation drill records up to nine months after the drill was allegedly conducted. Licensee_x001A_s actions constitute falsification of facility records and is a violation of Oregon Administrative Rules. UPDATE: FOP sent 7/30/14",3,500,,, +CO15005,592969,AFH,12/15/2014,Unqualified caregiver working alone on weekends from 10/12/14 through at least 12/15/14.,3,250,,, +HM116715,5MA003,RCF,3/30/2011,The facility failed to provide a safe environment and ensure safety measures for safe keeping of Resident #1's wallet and money. Resident #1's money was discovered missing from his/her wallet that was kept in a desk drawer in the facility office.,2,0,,,Financial abuse +HM117160,5MA003,RCF,5/28/2011,Resident #1 had a history of taking things from other residents and Resident #2's behaviors were known to be triggered by other residents in his/her space. Resident #2 grabbed Resident #1's hand and pushed it away when Resident #1 tried to take something away from Resident #2. Resident #1 did not suffer any injury.,2,0,,, +HM117622,5MA003,RCF,7/17/2011,"Resident #2's care plan noted history of physical aggression toward staff and residents, with interventions and redirection techniques. Resident #2 moved from the couch where he/she was sitting and walked over to where Resident #1 was sitting, and grabbed his/her hand causing a skin tear. When staff discovered the incident, the residents were separated.",2,0,,, +HM118812,5MA003,RCF,12/13/2011,"Resident #1 was known to wander. Resident #1 left his/her house, went through the yard to the other house, and was let out by Reported Perpetrator 2 who thought he/she was a visitor. Resident #1 wandered approximately a few blocks, fell and injured his/her head. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HM128875,5MA003,RCF,12/14/2011,"Resident #1 and Resident #2 were care planned having not gotten along and had history of aggression. Resident #1 took an object and headed to his/her room, Witness 1 intervened upsetting Resident #1 and subsequently Resident #2 creating an altercation. The facility failed to provide a safe environment. The failure violates Oregon Administrative Rules.",2,0,,, +HM128941,5MA003,RCF,12/26/2011,"Resident #1 and Resident #2 were care planned having history of aggression. Witness 1 was providing care to another resident and heard a commotion, discovering Resident #1 and Resident #2 had an altercation resulting in Resident #1 suffering a scratch on his/her face and hand. The facility failed to provide a safe environment for residents with behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HM129117,5MA003,RCF,1/8/2012,"Resident #2 was care planned having a history of aggression and had a new prescription for behaviors. Resident #1 was care planned needing assistance from others for safety. Resident #2 was agitated and began hitting Resident #1 while he/she slept. Resident #2 was noted to be agitated prior to this incident. The facility failed to provide a safe environment for residents with behaviors. The failures are a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +HM129158,5MA003,RCF,1/12/2012,"Resident #2 poked Resident #1 in the chest, resulting in an altercation and Resident #2 knocking off Resident #1's eyeglasses. Resident #2 was care planned having a history of aggression and had been agitated for a few days. Witness 1 failed to intervene at the first signs of agitation. The facility failed to provide a safe environment related to resident behaviors. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HM129259,5MA003,RCF,1/16/2012,Resident #1 and Resident #2 were care planned to be kept apart. Resident #2 and Resident #1 sat on the same couch and Resident #2 used his/her feet to push at Resident #1. Witness #3 failed to intervene at first signs of them sitting near each other. The facility failed to provide a safe environment related to resident behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HM129387,5MA003,RCF,1/27/2012,"Resident #1 and Resident #2 were care planned having a history of behaviors. Resident #1 and Resident #2's behaviors increased regarding a chair, chair cushions, and couch in the common area. Resident #1 pushed Resident #2 back almost falling; however a staff person caught him/her. The facility failed to provide a safe environment regarding resident behaviors. The failure is a violation of Oregon Administrative Rules.",2,250,,, +HM120704,5MA003,RCF,7/30/2012,Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) were involved and/or aware of Resident #1 being restrained in his/her wheelchair with a gait belt for approximately five hours. RP2 and RP3 are responsible for abuse by means of wrongful use of a physical restraint. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Restraints +HM121194,5MA003,RCF,9/16/2012,Reported Perpetrator 2 (RP2) repeatedly used profanity at the residents during the lunch meal time. RP2 is found responsible for verbal/mental abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HM121272,5MA003,RCF,9/19/2012,"Resident #1 and Resident #2 both had a history of physical aggression. On 9/19/12, Resident #1 and Resident #2 behaviors escalated resulting in a physical altercation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HM121516,5MA003,RCF,9/26/2012,"Resident #1 went into the bathroom in the night and remained sitting on the bathroom floor, refusing to come out. Between 6am-1:30pm, he/she became less and less responsive and slurred his/her words. Staff checked on him/her throughout the day offering food, water, juice, however he/she mostly declined. The facility failed to intervene when Resident #1 experienced a change of condition. Staff failed to report Resident #1's change of condition to the administrator or person in charge. Resident #1 was transported to the hospital for evaluation. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +HM121744,5MA003,RCF,11/15/2012,Resident #1 had money in his/her money clip on 11/14/12; however discovered his/her money and the money clip missing on 11/15/12. His/her roommates money was observed but it wasn't Resident #1's as his/her was folded and would have been creased from the money clip. An unknown individual is responsible for the theft of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +HM132412,5MA003,RCF,1/22/2013,The facility failed to provide a safe environment resulting in a non-injury physical altercation between Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,0,,, +PT132913,5MA003,RCF,3/21/2013,"The facility failed to provide a safe environment and protect residents from Resident #1's behavior. Resident #1's behavior escalated and affected Resident #2, Resident #3, and Resident #4 resulting in some injuries. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +HM133349,5MA003,RCF,5/9/2013,"Resident #1 reported missing money from his/her wallet. A family member confirmed Resident #1 had some money. Facility staff had access to Resident #1's apartment. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the money, which is considered Financial Exploitation and is considered abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +HM133368,5MA003,RCF,5/17/2013,"Resident #2 hit Resident #1, resulting in a scratch to Resident #1's hand. It was not the first altercation involving Resident #2. The facility failed to address a resident's behavior. The failure is a violation of Oregon Administrative Rules.",2,,,, +HM134652,5MA003,RCF,9/13/2013,"On 9/13/13, Resident #1 left the facility through the gate and was found approximately one (1) mile away. Resident #1 had a history of exit seeking behavior. The facility failed to ensure adequate staffing, failed to ensure staff were trained to his/her service plan; and failed to provide a functioning exit door alarm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HM146070,5MA003,RCF,1/22/2014,"The facility failed to provide a secure environment for Resident #1. He/she was able to elope from the facility through a gate left open by maintenance staff. Resident #1 had shown exit seeking behavior prior to this event. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +HM146104,5MA003,RCF,1/24/2014,"Resident #1 had documented history of verbal abuse and making accusations towards others, and Resident #2 had documented history of verbal and physical aggression towards others. Resident #1 and Resident #2 had a resident to resident altercation and Resident #1 was pushed down sustaining a bump on his/her head. The facility failed to adequately monitor Resident #1 and Resident #2. This failure is a violation of resident rights, is considered neglect of care and is abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +HM146656,5MA003,RCF,3/1/2014,"Resident #2 had a history of verbally and physically aggressive behaviors. Resident #2 hit Resident #1 during a resident to resident altercation. The facility failed to adequately intervene when Resident #2's behavior escalated. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HM147151,5MA003,RCF,5/9/2014,"On 5/9/14, Resident #1 left the facility when another resident opened the gate. He/she was found on a nearby street and returned to the facility without injury. The facility failed to provide a safe environment and failed to appropriately care plan for Resident #1's known history of eloping. The failures are a violation of Oregon Administrative Rules.",2,,,,Neglect +HM147471,5MA003,RCF,5/24/2014,"Resident #1 and Resident #2 had a physical altercation on 5/24/14 and again on 6/8/14. The facility failed to implement interventions and monitor for a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +HM149002,5MA003,RCF,9/26/2014,"Resident #2 had multiple resident to resident incidents, and both Resident #2 and Resident #1 had history of being physically aggressive. Resident #1 and Resident #2 had altercations on 9/26/14 and 9/27/14. On 10/2/14, Resident #3 was found on the floor with Resident #2 standing over him/her angry with clenched fists. The facility failed to ensure appropriate interventions were in place regarding behaviors. The failures resulted in an unsafe environment and are violations of Oregon Administrative Rules.",2,,,, +HM149017,5MA003,RCF,10/18/2014,"Resident #2 had a physical altercation with Resident #1 and also threatened to kill him/her. Resident #2 had history of physical aggression and had multiple recent resident to resident altercations. The facility failed to implement appropriate interventions to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HM149618,5MA003,RCF,11/22/2014,"For approximately two hours, Resident #1 was strapped into his/her wheelchair for safety due to frequent falls. The facility failed to adequately care plan related to his/her falls and failed to ensure sufficient staffing for resident safety, resulting in a wrongful use of restraint. The failures are a violation of resident rights, are considered neglect of care resulting in wrongful restraint.",2,,,,Restraints +HM149654,5MA003,RCF,11/1/2014,"On 11/1/14, Resident #1 and Resident #2 had a physical altercation with no injuries noted. Both residents had previous issues and altercations. The facility failed to ensure effective interventions to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,,, +HM159783,5MA003,RCF,11/20/2014,"Resident #2 hit Resident #1 on the side of the face, with no injuries noted. Both residents had a history of behaviors and previous incidents. The facility failed to ensure effective interventions to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,,, +HM159811,5MA003,RCF,12/8/2014,"Resident #1 had multiple falls, and many with injuries. He/she was a care planned for standby assist from staff; however he/she continued to fall with standby assist. The facility failed to adequately care plan related to falls to keep Resident #1 safe. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HM150471,5MA003,RCF,2/20/2015,"Resident #2 became mad and yelled at Resident #1 and also hit him/her. Resident #2 had been threatening other residents and had a history of aggression towards other residents. The facility failed to care plan and implement interventions regarding Resident #2's behavior making it an unsafe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HM152013,5MA003,RCF,6/8/2015,Residents #1 thru #7 were not provided appropriate toileting management resulting in incontinence. The facility's failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +HM151887,5MA003,RCF,7/5/2015,"Resident #1 was found outside, in the heat, unresponsive and was later diagnosed with heat exhaustion. Resident #1's medications were not administered as ordered. The facility failed to monitor Resident #1 and failed to maintain a safe medication administration system. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HM152015A,5MA003,RCF,5/11/2015,Resident #1 was not given breakfast one day when he/she wouldn't shower. He/she needed extensive assistance with showering; however his/her clothes were thrown at him/her and told to shower. The facility failed to ensure services were provided appropriately and with respect to Resident #1. The failures are a violation of resident rights and Oregon Administrative Rules.,2,,,, +HM152015B,5MA003,RCF,5/11/2015,"Reported Perpetrator 2 (RP2)'s behavior towards Resident #1 consisted of cussing, yelling, threatening, and gave ultimatums to shower before eating. The facility failed to provide a safe environment to be free from verbal abuse. The facilities failure violates Oregon Administrative Rules. RP2's actions are considered verbal abuse.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HM153278,5MA003,RCF,9/22/2015,"Resident #1 had a history of elopement. On 9/22/15, he/she eloped and was found at nearby apartments. The facility failed to implement and care plan interventions regarding his/her elopement behavior to ensure he/she was safe. The failures are a violation of resident rights and Oregon Administrative Rules.",2,,,, +BC150152,5MA016,RCF,1/30/2015,The facility failed to ensure a safe environment resulting in the elopement of Resident #1 from a secure memory care facility. Resident #1 was later discovered at a local business and returned unharmed the following day. The failure is a violation of Oregon Administrative Rules.,2,,,, +RS116562,5MA024,RCF,10/19/2010,A resident of the Facility was sent to the hospital for a medical condition at it was determined at that time the resident had dried feces in his/her peri area which was causing redness and minor skin breakdown. The Facility provided training to staff upon the notification of this incident by staff from the hospital.,2,0,,,Neglect +RB117733,5MA024,RCF,8/13/2011,"The Facility failed to keep Resident #1 and Resident #2 separated following an incident in Resident #1's room on 8/13/11. The following day, Resident #1 was found in Resident #2's room.",2,0,,, +RS129414,5MA024,RCF,3/5/2012,"Resident #1_x001A_s Narcotic Record was not accurate. After review, one pain medication was unaccounted for. The facility failed to keep Resident #1_x001A_s medication record accurate. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RB120747,5MA024,RCF,8/4/2012,"Resident #1 put his/her hand into the sharps container that was at the medication cart and was removing discarded medications and needles from the container. He/she had medications in his/her mouth. Resident #1 had a negative reaction and was transported to the emergency room. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO12124,5MA024,RCF,10/9/2012,"The facility failed to evaluate, develop appropriate interventions, monitor and provide an RN assessment. Resident #1 lost a severe amount of weight. Resident #2 experienced persistent diarrhea and weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,, +RB121188,5MA024,RCF,9/27/2012,Resident #1 was involved in an altercation with Resident #2. Resident #1 sustained scratches to his/her arm and forehead. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB121649,5MA024,RCF,11/13/2012,"Resident #1_x001A_s care plan states he/she becomes very upset if he/she has to wait very long to smoke. Resident #1 had just requested a smoke and was told he/she would have to wait. Resident #1 became upset, threw his/her coffee cup and was screaming and yelling. Resident #1 grabbed Resident #2 by the throat and had to be pried off of Resident #2. Resident #2 sustained visible red marks on his/her throat. The facility failed to address Resident #1_x001A_s behavior for safety. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO13011,5MA024,RCF,1/3/2013,"A re-licensure survey completed on January 3, 2012, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: The facility failed to provide an RN assessment and carry out physician_x001A_s orders. Resident #1 lost a severe amount of weight. Resident #2 lost a severe amount of weight and his/her physician_x001A_s orders were not followed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +RB121926,5MA024,RCF,12/18/2012,Resident #1 was awakened by Reported Perpetrator 2 (RP2) squirting water in his/her face from a spray bottle. The facility failed to assure Resident #1_x001A_s rights. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB132355,5MA024,RCF,2/6/2013,Resident #1 and Resident #2 were roommates. Resident #2 would pinch Resident #1 causing bruising. The facility failed to address Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB132837,5MA024,RCF,3/31/2013,"Resident #1 was found outside in the secured area face down on the sidewalk. He/she was transported to the hospital and received stitches. Resident #1 has a history of falls with injury. Resident #1 was care planned for ambulation with a walker and a one person assist. + +Resident #1 did not have a one person assist. The facility failed to follow Resident #1_x001A_s care plan resulting in injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB133290,5MA024,RCF,5/21/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #1 sustained a skin tear. The facility failed to address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB133435A,5MA024,RCF,6/4/2013,"Even though witnesses stated Resident #1 was showing signs of pain for two weeks; the only intervention implemented was giving Resident #1 a non-narcotic pain medication. Resident #1 was admitted to the hospital and diagnosed with a fever, dehydration and an infection. The facility failed to intervene when Resident #1's condition changed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB133642,5MA024,RCF,6/25/2013,Resident #1 was at risk for falls. His/her service plan stated that staff would walk with him/her using a gait belt and four wheel walker. Resident #1 fell while walking unassisted and sustained a cut above his/her eyebrow. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB148387,5MA024,RCF,8/29/2014,"Resident #2 had a history of violent temper and was easily angered. Resident #2's care plan stated he/she was to be kept in the line of sight and redirected as needed. Resident #2 had an altercation with Resident #1. Resident #2 pushed Resident #1 to the floor causing injury. + +The facility failed to follow Resident #2's care plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +RS150458,5MA024,RCF,3/1/2015,"The facility failed to adequately care plan to monitor Resident #1 when pushing other residents in their ambulation devices. On March 1, 2015 Witness #2 observed RV1 push RV2 down the ramp and then let go of the wheelchair. RV2 hit the wall at the bottom of the ramp and tipped over. This failure is considered neglect of care, which constitutes abuse and is a violation of the Oregon Administrative Rules.",2,,,,Neglect +RS151374,5MA024,RCF,5/22/2015,Resident #1 and Resident #2 were involved in an altercation. The facility failed to care plan interventions regarding Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RS152242,5MA024,RCF,7/23/2015,"Resident #2 punched Resident #1 in the face. This is the second altercation these Residents have been involved in, and Resident #1 has a history of similar behavior. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +RS152279,5MA024,RCF,7/23/2015,"Several residents had medication taken from the medication room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +RS152336,5MA024,RCF,7/29/2015,"The facility failed to adequately monitor Resident #1 and Resident #2. Resident #2 had a history of aggression towards others. Both residents were involved in an altercation and Resident #1 hit Resident #2. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +RS164213,5MA024,RCF,1/6/2016,"The facility failed to adequately monitor Resident #1 and Resident #2. Resident #1 was able to wander into Resident #2's room, and Resident #2 inappropriately touched Resident #1. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BC105828A,5MA031,RCF,11/9/2010,"Resident #1 was care planned for staff assistance with dressing and had ""long johns"" in his/her personal belongings. Resident #1 was not appropriately dressed for outside colder weather conditions when transported out for a medical appointment.",2,0,,, +BC105828B,5MA031,RCF,11/9/2010,Resident #1 had a physician's order to have a lap buddy on while in his/her wheelchair. Facility staff did not use the lap buddy while Resident #1 was seated near a table in the common area.,2,0,,, +BC118013,5MA031,RCF,9/14/2011,"Resident #1 was care planned to wear hip protectors and a tag alarm at all times. On 9/14/11, he/she was found on the floor without the tag alarm on and the padding from the hip protectors removed. Resident #1 was diagnosed with a hip fracture at the hospital.",3,300,,,Neglect +BC129722,5MA031,RCF,3/29/2012,"Resident #1 had a known history of aggressive behaviors and striking out at staff, and the service plan did not provide instruction or interventions to staff regarding his/her behaviors. Witness 1 enlisted Reported Perpetrator 2's (RP2) assistance in providing toileting care to Resident #1. Resident #1's behaviors increased and he/she hit RP2 in the chest. RP2 held Resident #1's gown in one hand and held Resident #1's hand with the other until he/she calmed down. There was no bruising or injuries following this incident. The facility failed to properly plan care relating to Resident #1's behaviors with staff. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC133135,5MA031,RCF,4/13/2013,"The facility failed to perform an adequate assessment on Resident #1 at move-in and failed to provide an accurate service plan reflecting his/her needs regarding risks of elopements and falls. Resident #1 had documented history of eloping two (2) times and attempting to elope twelve (12) times within approximately four months without implemented interventions for safety. Resident #1 successfully eloped from the facility, fell on the street, broke his/her nose and was transported to the hospital. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +BC134699,5MA031,RCF,6/13/2013,"Resident 1 had bilateral shin bruises of unknown origin discovered in April 2013, and left hand bruises of unknown origin discovered in May 2013. The facility failed to both report the discovery of these injuries to a local SPD office, or the local AAA as suspected abuse, promptly investigate these injuries for suspected abuse, and adequatley monitor and assess Resident 1's change of condition. The failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",2,,,,Neglect +BC153228,5MA031,RCF,10/19/2015,"The facility failed to adequately care plan, monitor, and document Resident #1_x001A_s weight and food intake/refusals. Resident #1 experienced an unreasonable significant weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES104588A,5MA042,RCF,6/14/2010,A Facility staff member administered incorrect medication to a resident. The medication belonged to another Facility resident. As a result of the medication error the resident experienced minor harm in the form of vomiting.,2,0,,,Neglect +ES104588B,5MA042,RCF,6/14/2010,A resident of the Facility was found to have suffered a fall from his/her wheelchair. It was determined the resident's care planned wheelchair safety restraint was not in place at the time of the resident's fall.,2,0,,,Neglect +ES129048,5MA042,RCF,1/25/2012,"Resident #1 was new to the facility, had exit seeking behaviors, and was checked on approximately every two hours. Resident #1 was found deceased in the outside courtyard, in an apparent attempt to climb the fence. The facility failed to have a functional exit door alarm on the courtyard door to alert staff, creating a risk of serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES120435B,5MA042,RCF,6/18/2012,"Resident #1 had a physician_x001A_s order to be given a protein shake when he/she ate less than 50 percent of his/her meal. There were 22 occasions recorded between June 12, 2012, and June 28, 2012, where he/she ate less than 50 percent of his/her meal. Protein shakes were not given during this time period. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES121365A,5MA042,RCF,10/18/2012,"Resident #1 reported that Reported Perpetrator 2 (RP2) yelled and screamed at him/her. Upon investigation, the investigator's findings were inconclusive regarding the allegation.",0,0,,, +ES121365B,5MA042,RCF,10/18/2012,Resident #1 waited approximately forty minutes for a caregiver to respond after he/she pushed their call button. Resident #1 required assistance due to feeling as though he/she was sliding out of bed. It is unclear why Resident #1 was not responded to; it was possible the call button was not working properly. The facility failed to provide care in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES132378A,5MA042,RCF,2/10/2013,Resident #1_x001A_s routine medication was being missed for various reasons. The facility failed to administer Resident #1_x001A_s medications as prescribed. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES134127,5MA042,RCF,8/14/2013,Resident #1 was involved in a verbal altercation with Resident #3. Resident #1 then had an altercation with Resident #2. Resident #1 and Resident #2 have a history of altercations. Both residents' service plans give directions to redirect away from other residents when displaying behaviors. The facility failed to follow service plans for Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES147579,5MA042,RCF,6/27/2014,Resident #1 and Resident #2 were involved in an altercation. Resident #1 had a history of resident to resident altercations. Resident #2 had a previous altercation involving three residents. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES148575,5MA042,RCF,9/12/2014,"Resident #1 had a history of altercations with other residents. Resident #1 was involved in an altercation with Resident #2. Resident #1 sustained injury. Two days later Resident #1 was involved in an altercation with Resident #3. Resident #1 sustained additional injury and Resident #3 sustained scratches to his/her face. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES148999A,5MA042,RCF,10/15/2014,"Resident #1 was prescribed a medication that was to be administered by the facility. Resident #1 did not receive this medication from October 15, 2014 to October 16, 2014 due to it not being available from the pharmacy. The facility failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES159768,5MA042,RCF,12/30/2014,"The facility failed to provide a safe environment resulting in Resident #1 sustaining a burn from hot soup. Resident #1 was transported to the hospital. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES148830,5MA042,RCF,10/6/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Resident #1 had a significant history of altercations with other residents. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES150646,5MA042,RCF,2/28/2015,"The facility failed to use the correct equipment when assisting Resident #1 with transfers. Resident #1 fell and sustained a scalp contusion. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BC134285B,5MA043,RCF,8/29/2013,Reported Perpetrator 2 (RP2) went into Resident #1's room and questioned him/her regarding an incident that took place earlier. Resident #1 said RP2 kept telling him/her they were confused regarding the incident and it didn't happen the way Resident #1 reported it. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated, +BC133111,5MA051,RCF,4/30/2013,While being trained by Reported Perpetrator 2 (RP2); Reported Perpetrator 3 (RP3) accidentally administered the wrong medication to Resident #1. The mistake was caught immediately and Resident #1 was sent to the emergency room as a precautionary measure. There were no serious side effects reported. The facility failed to administer mediation as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC146645,5MA051,RCF,4/5/2014,Resident #1 was observed with bruising to wrists and is known to bruise easily. Witness testimony and facility documentation revealed Resident #1 required more assistance with getting out of bed and staff had been observed holding onto the resident's wrist to help up. The facility failed to ensure proper staff training on appropriate resident transfers. It is unknown if the bruising was caused by improper transfers from staff. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC164288,5MA051,RCF,1/11/2016,"In May 2015, RV1 arrived at his/her clinic with his/her oxygen tank turned off and not functioning properly. In November 2015, RV1 arrived at his/her clinic and the oxygen tank was turned off. On January 11, 2016 RV1 arrived at his/her clinic with an oxygen tank that was malfunctioning. Witness #6 stated that staff should take the oxygen tubing off and ensure that air is flowing from the tank to the tubing. The facility failed to ensure that RV1's oxygen was functioning properly placing him/her at risk of harm.",2,,,, +AL146353,5MA080,RCF,9/30/2013,"Resident #1_x001A_s care plan indicated he/she was to wear a personal alarm to warn caregivers when he/she attempted to stand up out of his/her wheelchair. Resident #1 suffered an un-witnessed fall and sustained a hip fracture. The personal alarm was discovered turned to the _x001A_off_x001A_ position. The facility failed to ensure Resident #1_x001A_s personal alarm was on. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AL148956,5MA080,RCF,3/10/2014,"Resident #1 and Resident #2 reside in a secure memory care community due to diagnosis and each of histories of aigitated behavior. On or about March 10, 2014, Resident #1 and Resident #2 engaged in an altercation with resulted in harm to Resident #2. The facility failed to adequately monitor. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL153184,5MA080,RCF,10/13/2015,"RV1's service plan indicates that he/she can become very upset with other residents/staff and that in the past staff intervention was required over ten times per shift. On or about October 10, 2015, RV1 was observed by staff digging his/her nails into RV2's arm. RV2 pushed RV1 causing him/her to fall to the ground. The facility failed to provide a safe and secure environment. The facility's failure is a violation of the Oregon Administrative Rules.",2,,,, +ES104265,5MA106,RCF,5/8/2010,"A resident of the secured Memory Care Community led another resident out of the secure premises through an unlocked gate. The resident then locked the gate so the other resident could not return, placing that resident at risk of harm due to his/her medical status. The Facility's lack of a secured environment placed both residents at risk for harm.",2,0,,, +ES104449,5MA106,RCF,5/26/2010,"A resident admitted to the Facility with a known history of falls. The Facility initially evaluated the resident as at risk for falls, but did not indicate that on the resident_x001A_s service plan. The resident experienced falls while at the Facility, and at the quarterly service plan update, no changes were made to the service plan with respect to the resident's falls.",2,0,,,Neglect +ES105626,5MA106,RCF,9/18/2010,"The Facility admitted a resident to their secured unit. After admittance the resident displayed, on several occasions, his/her ability to leave the secure unit by bypassing the Facility's door security. The resident demonstrated that he/she was not an appropriate placement for the Facility.",1,0,,, +ES116084A,5MA106,RCF,12/1/2010,"A resident of the Facility went to his/her dentist with mouth pain. It was discovered the Facility had been putting another resident's dental appliance in the resident's mouth, causing the resident discomfort and pain, which resulted in the visit to his/her dentist.",2,0,,,Neglect +ES116084B,5MA106,RCF,12/1/2010,A resident of the Facility experienced a loss of several personal items over the time he/she was a resident. Items such as prescription glasses and shoes were found to be missing.,2,0,,,Financial abuse +ES116340,5MA106,RCF,2/13/2011,Resident #1 was admitted to the Facility with a known history of wandering and exit seeking that previously resulted in the resident getting lost. From the time resident #1 admitted to the Facility he/she displayed exit-seeking behaviors. The resident eloped from the Facility and was later found by law enforcement in another town many miles from the Facility going through a dumpster. The resident did not have any apparent injuries.,2,0,,, +ES116446,5MA106,RCF,2/25/2011,A resident who was being transferred to another facility was sent out with another resident_x001A_s medications. Facility staff went and retrieved their resident_x001A_s medications and returned the appropriate medications. Neither resident missed an administration of medication or experienced any negative outcome.,1,0,,, +ES105580,5MA106,RCF,10/23/2010,It was determined that a resident of the Facility was allowed to pop pills and dispose of them for a Facility staff member who was preoccupied with other duties. The resident had a history of erratic behavior and having access to medications in such a way presented as potentially harmful to the resident.,1,0,,, +ES116899,5MA106,RCF,5/3/2011,"A resident of the Facility who was care planned as being resistive to care was noted to have tape residue on his/her backside, most likely due to refusing showers from Facility staff.",1,0,,, +ES116794A,5MA106,RCF,4/19/2011,"Resident #1 would exhibit increased behaviors, usually related to a urinary tract infection. For approximately two weeks, his/her behaviors increased toward staff and other residents however a test was not conducted. Resident #1 tested positive for a urinary tract infection.",2,0,,,Neglect +ES116794B,5MA106,RCF,4/19/2011,"Resident #1 had no prior skin issues and skin was to be monitored on shower days. Between 3/31/11 - 4/19/11, he/she was showered twice (dates unknown). On 4/19/11, Resident #1 was found to have had a pressure sore on his/her coccyx.",2,0,,,Neglect +ES116697A,5MA106,RCF,3/31/2011,A resident of the Facility was not showered according to his/her schedule. The Facility could not provide evidence that a shower took place as scheduled. The resident did not experience harm as a result of not receiving a shower as scheduled.,1,0,,, +ES116697B,5MA106,RCF,3/31/2011,"A resident of the Facility displayed aggressive behaviors. The resident's physician prescribed medication to address those behaviors. Once the medication became effective, the resident's behaviors seemingly ended.",0,0,,, +ES118282A,5MA106,RCF,10/21/2011,Resident #1 left the facility without assistance by climbing over the fence. His/her service plan did not address his/her elopement risk or history. The facility failed to provide a safe environment and the failures is a violation of Oregon Administrative Rules.,2,0,,, +ES118282B,5MA106,RCF,10/21/2011,Resident #2 left the facility without assistance by climbing over the fence. Law enforcement found him/her; however the facility staff were not aware that he/she had eloped. Resident #2's service plan did not address his/her elopement risk or history. The facility failed to provide a safe environment and the failures is a violation of Oregon Administrative Rules.,2,0,,, +ES118044A,5MA106,RCF,9/14/2011,Resident #1_x001A_s pre-admission screening goal was to increase his/her weight . The facility did not put a care plan into place to increase Resident #1_x001A_s weight. Resident #1 lost weight. The facility failed to appropriately care plan and the failure is a violation of Oregon Administrative Rule.,2,0,,, +ES118392,5MA106,RCF,11/5/2011,"Resident #1 pushed Resident #2 and #3. There were no injuries. Resident #1 had exhibited behaviors and aggression toward care staff. The facility failed to provide a safe environment for Resident #2 and #3. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,, +ES134396,5MA106,RCF,9/4/2013,Resident #1 developed a skin condition in early July 2013. A treatment order from Resident #1's physician was not implemented until mid-September. The facility failed to provide appropriate treatment in a timely manner and update his/her service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES146551,5MA106,RCF,3/29/2014,"Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES135211,5MA106,RCF,11/25/2013,"Resident #1 was missing from the facility. He/she was missing for approximately twenty hours. He/she was found inside a locked closet in a vacant room. Staff did not check the closet because it was locked. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES153561,5MA106,RCF,11/12/2015,Resident #1 reported $40.00 missing from his/her lockbox. The lockbox had indications that it had been broken into. Resident #2 had a history of going into other resident rooms. Resident #2 had been seen attempting to open Resident #1's lockbox. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC117956,5MA107,RCF,9/2/2011,"Resident #1 does not like other residents in his/her room. Resident #2 had a history of wandering into others_x001A_ rooms. On 8/21/11 and 9/2/11, Resident #2 wandered in Resident #1_x001A_s room resulting in a resident to resident altercation.",2,0,,, +BC118803,5MA107,RCF,12/27/2011,"Resident #1 wore geri-sleeves at all times and had additional padding to protect his/her arms. His/her service plan was updated to provide a two person transfer after a bruise was found on his/her left forearm on 12/27/11. Between 12/28/11 and 12/29/11, Resident #1 was found with a bruise to his/her right forearm. An unknown individual is responsible for rough handling causing Resident #1 bruising. The facility failed to provide a safe environment and the failure is a violation of resident rights.",2,0,Not Substantiated,Substantiated,Physical Abuse +BC129732,5MA107,RCF,3/24/2012,"Resident #1 was care planned to use a gait belt only; however he/she expressed pain when using a gait belt for transfers. Staff reported an ""understanding"" that using a pad was an acceptable method to transfer him/her. There were two pads under Resident #1 and RP2 and RP3 each grabbed a different pad and he/she fell and bumped his/her head causing unreasonable discomfort. Resident #1 was evaluated at the hospital and no injuries noted. The facility failed to properly plan care and provide clear direction to staff. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC120865,5MA107,RCF,8/13/2012,"Resident #1 had memory impairment; ambulated with a wheelchair, and was dependent in all Activities of Daily Living; and was care planned for ""fragile skin."" On 8/14/12 at 1:30am, he/she was found to have an injury by a staff person; however the injury wasn't reported to facility administration until 7:30am. It was not determined exactly when, where or how it happened, or who might be responsible. The facility failed to provide a safe environment and staff failed to timely report the injury. The failure is a violation of resident rights, is considered neglect of care resulting in physical abuse and constitutes abuse.",2,0,,,Physical Abuse +BC120675,5MA107,RCF,7/29/2012,Resident #1 resisted Reported Perpetrator 2's (RP2) efforts of care and Resident #1 stiffened up his/her body. RP2 grabbed the back of Resident #1's neck and directed Resident #1 to his/her feet and took him/her to an empty room where he/she fell against a padded chair. RP2's actions to Resident #1 were physically abusive. The facility failed to provide a safe environment resulting in rough treatment to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +BC121847,5MA107,RCF,11/28/2012,"Resident #1's liquid narcotic medication was discovered to have been tampered with. Upon investigation, it was determined Reported Perpetrator 2 (RP2) is found responsible for the theft of Resident #1's medication, which constitutes financial exploitation and is considered abuse. Resident #1 did not go without his/her medication. The Facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +CO15028,5MA107,RCF,1/28/2015,See License Condition #RCFCP15-002,3,,,,Neglect +BC164560,5MA107,RCF,2/5/2016,"Resident #1's care plan was not followed for a two person assist for transfers, exposing him/her to potential harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM116880,5MA130,RCF,4/29/2011,"The Facility failed to implement treatment orders to Resident #1_x001A_s left hallux (great toe) resulting in amputation. Facility documentation did not indicate the treatment orders were followed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +MM132614,5MA130,RCF,3/7/2013,Resident #1 had exhibited physical aggression toward him/her self and others since December 2012. No changes to his/her service plan or interventions were implemented until March of 2013. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM152459,5MA130,RCF,8/6/2015,The facility failed to adequately monitor Resident #1. Resident #1 was able to leave the facility without staff knowledge. This failure is a violation of Oregon Administrative Rules.,2,,,, +MM152992,5MA130,RCF,9/29/2015,"The facility failed to adequately provide a safe environment in relation to altercations between Resident #1 and Resident #2. Resident #2 had pushed Resident #1 in a previous altercation. Resident #2 pushed Resident #1 down again causing head and back injuries. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +KF105591,5MA131,RCF,10/30/2010,"A Facility staff member, Reported Perpetrator #2 (RP2), undressed a resident who was resisiting care. The staff member was showering the resident against his/her wishes. The resident sustained bruising on and/or around his/her wrists following the incident.",2,0,Not Substantiated,Substantiated,Physical Abuse +KF118164,5MA131,RCF,10/3/2011,"Resident #1 was a known fall risk. Early in the morning on September 25, 2011, Resident #1 fell and fractured her/his wrist. Resident #1 was not transported and treated for her/his injuries for several hours. The facility failed to timely seek medical attention resulting in ongoing pain and suffering. The facility also failed to appropriately care plan after Resident #1 experienced several falls in her/his room. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF118320,5MA131,RCF,10/28/2011,Resident #1 requires assistance with toileting needs. The facility failed to follow care plan resulting in the resident developing a painful yeast infection in the groin area.,2,0,,,Neglect +KF104124,5MA131,RCF,4/26/2010,"Resident #1 had a medical condition that caused him/her to develop skin wounds easily. + +He/she had several wounds on his/her legs and feet. The facility did not follow the wound clinic instructions to keep the foam boot on Resident #1_x001A_s left foot and to keep the bandages dry. Resident #1 contracted an infection in his/her wounds. The facility failed to follow Resident #1_x001A_s care plan. The facility also failed to follow Resident #1_x001A_s physician_x001A_s order for monthly weight checks regarding his/her needed assistance with eating and nutrition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,0,,,Neglect +KF128888,5MA131,RCF,12/28/2011,Resident #1 entered Resident #2's room through an adjoining bathroom during the night. An altercation ensued leaving Resident #2 with injuries. Resident #1 had recent history of entering other resident's rooms.,2,0,,,Neglect +KF129154,5MA131,RCF,2/5/2012,"Resident #2 was found standing over Resident #1 making threatening statements. Resident #1 sustained injuries to his/her face. Resident #2 was care planned to be supervised at all times due to a recent similar altercation with another resident. The facility failed to address Resident #2_x001A_s behaviors and follow his/her care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +KF135346,5MA131,RCF,11/18/2013,Witness #1's dog bit Resident #1 on the finger. Facility staff was aware of the dog's aggressive demeanor. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF135245,5MA131,RCF,11/28/2013,"Resident #1 has a Tilt Wheel Chair he/she uses for safety. Resident #1's care plan was never updated to indicate Resident #1 should be in a tilt position while seated in the wheelchair, despite indications Resident #1 can lean forward out of the chair if it is not tilted back. The facility failed to properly care plan. This failure is a violation of Oregon Administrative Rules.",2,300,Substantiated,Substantiated, +KF146061,5MA131,RCF,2/8/2014,"The facility failed to assess and implement adequate fall interventions for Resident #1 following several falls. On February 8th 2014, Resident #1 fell again and sustained an injury to the back of the head requiring stitches. The facilities failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",3,300,,,Neglect +KF147329,5MA131,RCF,6/7/2014,"Resident #1 was designated a high fall risk. There were no updates to Resident #1's care plan regarding his/her fall risk. Resident #1 experienced a fall resulting in a fractured hip. The facility failed to adequately update Resident #1's care plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF148513,5MA131,RCF,9/10/2014,"Reported Perpetrator 2 (RP2) was a staff member at the facility with duties that included providing direct care to residents. RP2 was found in a suspicious manner with Resident #1 when RP2 was supposed to have been off duty. RP2 admitted to having Resident #1 perform a sexual act on RP2. RP2's actions were a significant violation of resident rights and constitutes sexual abuse. The facility failed to provide a safe environment for Resident #1 resulting in sexual abuse. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse.",4,2500,Substantiated,Substantiated,Sexual abuse +KF149400,5MA131,RCF,11/28/2014,"Resident #1 experienced four falls during a two week period. The falls caused Resident #1 pain and anxiety. Resident #1's care plan stated a tab alarm was to be on at all times. Resident #1's physician's order indicated Resident #1 required extra assistance with ambulation and transfers. The facility failed to adequately update Resident #1's care plan to address fall interventions. The facility also failed to follow Resident #1's care plan relating to the tab alarm being on at all times. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF149579,5MA131,RCF,12/13/2014,"The facility failed to address Resident #1's behaviors resulting in a physical altercation with Resident #2. Resident #1 had a history of aggressive behaviors. Resident #2 sustained skin injuries. The failure is a violation of resident rights, is consider neglect of care and constitutes abuse.",2,,,,Neglect +KF149546,5MA131,RCF,12/9/2014,"Resident #1 had a history of wandering at night time. He/she wandered into another resident_x001A_s room and fell. Resident #1 was transported to the hospital where he/she was diagnosed with a left wrist fracture. The facility failed to adequately update Resident #1_x001A_s care plan to address monitoring and wandering at night time. The facility also failed to have appropriate staffing coverage. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF148834,5MA131,RCF,10/7/2014,Resident #2 was observed on the facility couch with his/her hand down Resident #1's shirt. Resident #2 was redirected. The facility failed to care plan for Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF149066,5MA131,RCF,10/28/2014,"Resident #1 and Resident #2 were involved in an altercation resulting in injury to Resident #1. Resident #2 did not sustain injury. Resident #1 was slapped by Resident #2 and sustained a bite to his/her right middle finger. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO15090,5MA131,RCF,2/5/2015,"The facility failed to implement and follow a smoking policy for five residents who were observed during the survey smoking unsafely. Resident #2's bed was observed to have an assistive device attached. There was no documented evaluation of the assistive device and it was not included in the current service plan. Resident #2 also had no evaluation regarding his/her sexually inappropriate behaviors and falls. Resident #3 experienced a significant change of condition related to uncontrolled pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +KF150228,5MA131,RCF,2/10/2015,"Resident #1 pushed Resident #2 causing him/her to fall. Resident #2 sustained skin tears as a result of the fall. The facility failed to implement interventions regarding Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +KF153027,5MA131,RCF,8/11/2015,"Resident #1 suffered from a metabolic disorder and was exhibiting signs of low blood sugar that included being weak and off balance. Resident #1_x001A_s care plan stated he/she was to use a walker at all times. Resident #1 had three falls on 7/25/15, 8/2/15 and 8/7/15. Resident #1 fell a fourth time resulting in a broken hip. The facility failed to follow Resident #1_x001A_s care plan, and assess and intervene when Resident #1 experienced a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF152260B,5MA131,RCF,7/21/2015,"Resident #4 was a fall risk. Resident #4's care plan only stated he/she did not get out of bed very often. He/she had eight incidents of falling or being found on the floor between 6/5/15 to 7/23/15. The facility failed to update Resident #4's care plan to reflect his/her needs and implement interventions for falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF154079,5MA131,RCF,12/29/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 had a history of wandering into other resident rooms, causing fear. No injuries were sustained. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.",2,,,, +KF154059,5MA131,RCF,12/28/2015,"Resident #1 had cognitive impairments and also had a colostomy bag which he/she would play with causing leakage. Resident #1 had been found with feces on him/herself and other areas. No documentation indicating Resident #1's colostomy was being managed was found. + +The facility failed to provide appropriate care to Resident #1; failed to provide appropriate staffing levels and appropriately care plan for Resident #1's needs. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +OR0001018701,5MA131,RCF,10/21/2015,,0,,,Substantiated, +NB132323,5MA137,RCF,1/27/2013,Resident #3 was involved in several resident altercations during a short period or time resulting in resident injuries. The facility failed to address Resident #3_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB145640,5MA137,RCF,7/1/2013,"Resident #1 lost a ring. The ring was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +NB146729,5MA137,RCF,4/12/2014,"Resident #2 had a history of agitated and aggressive behavior including physical altercations with other residents. Resident #2 experienced three known altercations with other residents. The facility failed to appropriately care plan Resident #2's continued behaviors. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB147235,5MA137,RCF,5/28/2014,Resident #1 splashed warm coffee onto Resident #2's face. Resident #2 did not have a negative outcome as a result of the incident. Facility documentation revealed Resident #1 was care planned to have a lid on her/his drinks due to past history of throwing coffee on others. The facility failed to follow the care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO14216,5MA137,RCF,9/18/2014,"The facility failed to ensure residents were consistently monitored and evaluated including documented RN assessments. Resident #1 experienced a fractured left ankle, Resident #2 experienced ongoing lower extremity wound infections and Resident #3 experienced hand wounds. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,900,,,Neglect +HB129101,5MA146,RCF,1/30/2012,Reported Perpetrator 2 (RP2) intentionally sprayed Resident #1 in the face with water and then laughed. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB129143,5MA146,RCF,2/2/2012,Resident #1 eloped from the facility in his/her wheelchair without assistance and fell backward striking the back of his/her head on the ground. Resident #1 was assessed for injuries and none noted. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB120327,5MA146,RCF,6/19/2012,Resident #1 was going to be out of the facility for the day and made advance arrangements for his/her medications to be taken with him/her. Resident #1_x001A_s 8:00 a.m. and 2:00 p.m. medications were placed in a pouch and were left in the medication cart by Reported Perpetrator 2 (RP2). RP2 had signed out the medications as being given to Resident #1 and they were not given to Resident #1. The facility failed to give Resident #1 his/her medications. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB120742,5MA146,RCF,7/31/2012,Resident #1_x001A_s narcotic medications were ordered from a specialty pharmacy and delivered to the facility via UPS. The package was signed for at the facility. At some point after delivery the package of 180 narcotic tablets came up missing. The theft of medications resulted from the actions of an unknown individual. The faculty failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB120985,5MA146,RCF,9/5/2012,Resident #1 had a significant change of condition. The facility failed to intervene when Resident #1_x001A_s condition changed. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB133214X,5MA146,RCF,5/14/2013,Resident #1 has impaired cognition and eloped from the facility. Resident #1 fell and sustained scraped knees. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB133581,5MA146,RCF,6/14/2013,Resident #1 reported money missing from his/her apartment. An unknown individual is responsible for the loss of Resident #1_x001A_s money. Resident #1 did not have a place to secure his/her money due to the lock box in their room being broken. The facility failed to provide a safe environment for Resident #1 resulting in the loss of money. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated, +HB134586,5MA146,RCF,10/1/2013,"Resident #2 has a history of aggressive behaviors toward staff and other residents. In September 2013 Resident #2 exhibited aggressive behaviors and struck Resident #1 resulting in a black eye. The facility failed to monitor and implement interventions to prevent altercations between Resident #2 and other residents. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +HB147340,5MA146,RCF,6/10/2014,"Resident #1 went on an outing in the facility bus. Upon return to the facility, Resident #1 was left on the bus in his/her wheelchair. Witness statements vary from a few minutes to fifteen minutes. Resident #1 requires assistance with all ADL's. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB159866,5MA146,RCF,1/8/2015,The facility failed to check Resident #1's O2 saturations as ordered. Resident #1 went several shifts without having his/her O2 saturations recorded. This failure is a violation of Oregon Administrative Rules.,2,,,, +SV105819,5MA151,RCF,10/20/2010,"The facility failed to provide a safe medication administration system resulting in Resident #2 being sent to the hospital for treatment of symptoms related to a medication error. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +SV116465,5MA151,RCF,3/4/2011,RP2 physically forced Resident #1's hand from a side rail causing a skin tear.,2,0,Not Substantiated,Substantiated,Physical Abuse +SV117463,5MA151,RCF,7/13/2011,Resident #1 reported missing at least $50.00 from her/his wallet. The facility failed to ensure a safe environment resulting in the loss of resident property. An unkown person was cited for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MV134354,5MA151,RCF,9/7/2013,"Several facility staff were aware on at least two separate occasions during a night shift that Resident #1 was in pain. In addition, it was reported Resident #1 had a skin tear. Resident #1's Medical Administration Record (MAR) indicated he/she had a physician's order for a PRN (as needed) pain medication from a previous hip fracture. The MAR reflected Resident #1 did not receive pain medication or assessment and/or treatment for the skin tear on the night he/she complained of pain. The following day Resident #1 was transported to the hospital and diagnosed with a hip fracture. The facility failed to provide service to address Resident #1's pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Not Substantiated,Substantiated,Neglect +MV134222,5MA151,RCF,8/25/2013,"Resident #1 and Resident #2 had histories of aggressive behavior. The facility failed to adequately care plan resulting in a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV121979,5MA151,RCF,12/25/2012,"Resident #1 had a diagnosis related to memory impairment. On or about December 25, 2012, facility staff discovered Resident #1 was missing. Resident #1 was discovered on the floor in an unlocked maintenance room over 12 hours later and required transportation to the hospital for treatment. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil money penalty is warranted, however one was not issued due to the timeframe between the investigation and when it was processed by the Department.",3,,,,Neglect +MV149163,5MA151,RCF,11/4/2014,"Resident #1 had a history of aggressive behavior. The facility failed to adequately care plan and monitor Resident #1 after she/he experienced aggressive behavior resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +MV149468,5MA151,RCF,11/1/2014,"Resident #1's ring and necklace was reported missing. An internal investigation was conducted and local law enforcement notified, however the items were not located. The facility failed to ensure a safe environment resulting in the loss of resident property. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +MV151857,5MA151,RCF,7/8/2015,"Resident #2 had a history of wandering and opening other residents' doors. Resident #1 pushed Resident #2 after attempting to open Resident #1's door. Resident #2 suffered a laceration and bruising. The facility failed to care plan for Resident #2's behaviors resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV152702,5MA151,RCF,9/3/2015,"The facility failed to adequately address Resident #1's behavior resulting in a physical altercation with Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC118666,5MA160,RCF,12/9/2011,Resident #1_x001A_s physician ordered meal supplement shakes to improve his/her intake and weight loss. The facility failed to monitor and document his/her intake or refusals of the meal supplement shakes; and failed to provide an evaluation of the effectiveness of this intervention or report back to his/her physician. Resident #1's condition worsened. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC129036,5MA160,RCF,11/28/2011,"Resident #1 was care planned as difficult to shower. Resident #2 and Resident #3 had approximately 27 tablets, within three months, of a PRN psychotropic medication that was unaccounted for that was allegedly administered to Resident #1 for the convenience of staff to shower him/her. There were no documented or observed ill effects for Resident #1. The facility failed to have a tracking system for psychotropic medications, failed to review all medications every ninety days, and failed to provide professional oversight thus rendering an unsafe medication system. The failures are a violation of Oregon Administrative Rules.",2,0,,, +BC120098,5MA160,RCF,5/9/2012,"Resident #1's care plan was updated in April 2012 because he/she bruised easily possibly due to the transfer method. All staff, except Reported Perpetrator 2 and Reported Perpetrator 3 followed the new care plan; however Resident #1 continued to sustain bruising. The facility failed to properly plan care for Resident #1 to reduce and/or eliminate the cause of bruising. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC134837,5MA160,RCF,9/5/2013,"The facility failed to assess and implement adequate interventions around Resident #1's aggressive behavior, and failed to provide a safe environment for Resident #2 when moved into Resident #1's room. On 09/5/13 Resident #2 pushed Resident #1 down during an altercation and Resident #1 sustained a fractured hip and wrist. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse. This Notification of Findings was issued in lieu of a civil penalty due to a change of ownership.",3,,,,Neglect +BC150290,5MA160,RCF,2/12/2015,"Staff had observed Reported Perpetrator 2 (RP2) being rough with residents, by grabbing a wrist or an arm, and staff also observed RP2 being loud with residents. The facility failed to ensure staff reporting of potential abuse to ensure a safe environment, exposing residents to potential harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC150768,5MA160,RCF,3/25/2015,"The facility failed to timely assess and care plan Resident #1_x001A_s change of condition before he/she returned from a ten day hospitalization to ensure safety. On the day of return, he/she got up, walked approximately 4 steps and fell resulting in a hospital transportation and was diagnosed with a fractured hip. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC151114,5MA160,RCF,4/26/2015,Resident #1 yelled at Reported Perpetrator 2 (RP2) and RP2 yelled back and grabbed his/her arm to push him/her towards his/her room. Resident #1 fell and had injuries to his/her right arm and leg. RP2's actions are considered physical abuse. Staff witnesses failed to timely report the incident. The facility failed to ensure staff reported abuse and failed to provide a safe environment which violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BC152529,5MA160,RCF,8/16/2015,"Resident #1 and Resident #2 had an altercation resulting in lacerations to Resident #2's head. Both residents had had several verbal altercations with each other. The facility failed to care plan and implement interventions to address behaviors to ensure a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +BC152747,5MA160,RCF,9/7/2015,"Resident #1 had cognitive issues, was a fall risk, and was care planned needing a two person assist when he/she is tired. Resident #1 was found tied to his/her wheelchair with two plastic bags; however without injuries. Reported Perpetrator 2 (RP2) tied his/her hands to prevent from falling. RP2's actions are considered a wrongful use of a restraint which constitutes abuse. The facility failed to provide a safe environment and failed to ensure Resident #1's care plan was followed when needing two persons help. The failures are a violation of resident rights and Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Restraints +MS129491,5MA161,RCF,3/13/2012,"Resident #1 and Resident #2 were involved in an altercation resulting in injuries. + +Resident #1 wandered into Resident #2_x001A_s room. The facility failed to address Resident #1 and Resident #2_x001A_s behavior for safety. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS129948,5MA161,RCF,4/29/2012,Resident #1 and Resident #2 were involved in an altercation with no injuries. Resident #1 wandered into Resident #2_x001A_s room. Both have a history of behaviors. The facility failed to follow service plans for Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MF120215B,5MA161,RCF,4/29/2012,It was reported that Resident #1 was served food that could cause him/her to choke. The facility failed to assure Resident #1_x001A_s service plan was being followed. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS121279A,5MA161,RCF,8/11/2012,"Reported Perpetrator 2 (RP2) administered two doses of another residents_x001A_ antibiotic to Resident #1 instead of his/her own prescribed antibiotic. Resident #1 had a known allergy to the antibiotic and his/her condition worsened. RP2 is found responsible for neglect. The facility failed to provide a safe medication administration system resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS121279B,5MA161,RCF,8/11/2012,"Resident #1 sustained approximately eleven non-injury falls and four injury falls between July 5, 2012 and August 15, 2012. The facility failed to appropriately care plan fall interventions for Resident #1 who exhibited cognitive deficits. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS132132,5MA161,RCF,1/14/2013,"Resident #1 was involved in two altercations involving Resident #2 and Resident #3. There were no injuries. On both occasions Resident #1 was observed to be agitated. No interventions were documented or attempted. + +The facility failed to follow Resident #1_x001A_s service plan relating to interventions when he/she is agitated. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS121418,5MA161,RCF,10/24/2012,Resident #1 and Resident #2 were involved in an altercation. There were no injuries. Resident #1 has a history of altercations with other residents. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS132564,5MA161,RCF,3/5/2013,"Resident #1 has a long history of verbal and physical aggression. Most recently, Resident #1 has been involved in altercations with Resident #2. Resident #1_x001A_s service plan addresses his/her physical aggression, however physical altercations continue to occur. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS132598,5MA161,RCF,3/8/2013,"Resident #1 and Resident #3 have a history of verbal and physical altercations. Most recently, Resident #1 hit Resident #2 then Resident #2 hit Resident #1. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS133803,5MA161,RCF,7/15/2013,"Resident #2 tried to crawl into Resident #1's bed causing an altercation. Resident #1 sustained two skin tears on his/her leg. Resident #2 has a history of being aggressive with other residents and staff. The facility failed to address Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS134180,5MA161,RCF,8/13/2013,Reported Perpetrator 2 (RP2) spoke and acted inappropriately toward Resident #1. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS134841,5MA161,RCF,10/24/2013,Reported Perpetrator 2 (RP2) insisted that Resident #1 shower and was overly rough causing him/her pain. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +MS133610B,5MA161,RCF,6/25/2013,"Resident #1 had several falls while at the facility. No amendments were made to his/her service plan. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS134314,5MA161,RCF,9/4/2013,Resident #1 has a history of bruising due to bumping into things. He/she propels self in wheelchair around the facility. Resident #1 had bruising on his/her forearms and right upper arm. The facility failed to care plan to address interventions to prevent bruising. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS146103,5MA161,RCF,2/14/2014,Resident #1 and Resident #2 were involved in an altercation. The facility failed to address Resident #2_x001A_s behavior and put interventions into place to deal with his/her behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS146102,5MA161,RCF,2/14/2014,Resident #1 and Resident #2 were involved in an altercation. Resident #2 rammed his/her ambulation device into Resident #1. No injuries were sustained. Resident #2 has a history of aggression. The facility failed to address Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS145984C,5MA161,RCF,1/31/2014,Resident #1 had a history of falls. He/she had eight un-witnessed falls from 11/2/13 to 1/21/14. On 2/2/14 Resident #1 had a witnessed fall and sustained two fractures in his/her left hand. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS146946C,5MA161,RCF,4/8/2014,"Resident #2 had a history of falls. Resident #2 had fourteen falls between 1/9/14 and 4/1/14. Eleven of those falls were injury falls. No interventions were put into place to reduce his/her falls until 2/18/14. The facility failed to adequately update Resident #2's service plan to address fall interventions. Due to the facility's history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility is on a current condition (condition #RCFCD14-010) a civil penalty will not be issued.",3,,,,Neglect +MS134485,5MA161,RCF,9/20/2013,Resident #1 is a fall risk. Resident #1 had bruising from an unknown cause. Resident #1's service plan also states he/she is verbally and physically aggressive with no behavior interventions in place. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS146236,5MA161,RCF,3/1/2014,Resident #1 was a fall risk and had several falls with injury. There were no amendments made to his/her service plan after each fall. The facility failed to update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS146633,5MA161,RCF,4/7/2014,Resident #1 is a two-person transfer at all times. Reported Perpetrator 2 (RP2) transferred Resident #1 without the assistance of another caregiver. Resident #1 sustained a skin tear on his/her shin. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS134795,5MA161,RCF,10/21/2013,"Resident #1 slapped Resident #2's hand. Both residents have a history of negative behaviors and verbal aggression. Both residents have been involved in altercations in the past. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS135080,5MA161,RCF,11/14/2013,Resident #1's service plan states he/she is independent with mobility and transfers. Resident #1 is also a fall risk per his/her service plan and he/she has sustained numerous falls with injury. No amendments were made to his/her service plan after each fall. The facility failed to update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,1,,,, +MS135461,5MA161,RCF,12/23/2013,It was discovered that Resident #1 had bruising from an unknown cause. Resident #1 had a history of falls and was service planned for full hands on assist when ambulating. The facility failed to update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS147058,5MA161,RCF,5/14/2014,"Resident #1 was independent with ambulation and transfers upon admission to the facility. Resident #1 had three falls with injury in a short period of time. The third fall resulted in Resident #1 being transported to the hospital for treatment. The facility failed to assess Resident #1 for a change of condition and service plan regarding falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS134501,5MA161,RCF,9/20/2013,"Resident #1 slid from his/her recliner sustaining a skin tear. Resident #1's service plan did not address safety while he/she was in the recliner. He/she had sustained an injury from a prior incident of sliding from the recliner that was not reported to APS. Resident #1's service plan, progress notes and staff statements were inconsistent regarding how frequently he/she was to be checked. The facility failed to properly plan Resident #1's care and report incidents to APS. The failures are a violation of Oregon Administrative Rules.",2,,,, +MS134528,5MA161,RCF,9/11/2013,"Resident #1 had seven falls between 8/17/13 and 9/11/13. No amendments were made to his/her service plan and he/she was not assessed for a change of condition. Resident #1 slipped and fell on the floor sustaining a broken hip. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions and assess Resident #1 for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS145570A,5MA161,RCF,1/3/2014,It was reported that Resident #1 spits out his/her medications and has a pattern of refusing medications. The investigator did not find an order for crushing medications from Resident #1's physician. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS146080,5MA161,RCF,2/12/2014,"Resident #1 was involved in an altercation with Resident #2 with no injuries. Resident #1 has a history of hitting other residents and being verbally aggressive. Resident #1 and Resident #2 have been involved in previous altercations. The facility failed to implement interventions to address Resident #1's aggressive behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO14137,5MA161,RCF,7/9/2014,"The Facility failed to provide effective administration oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed July 9, 2014 (P5BN12).",3,,,,Neglect +MS135117,5MA161,RCF,11/15/2013,"Resident #1 has a history of combative behavior. Resident #2 has a history of verbal and physical aggression. Resident #1 and Resident #2 were involved in an altercation. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS146388A,5MA161,RCF,3/17/2014,"Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Both residents have a history of altercations. No service plan adjustments were made for either resident. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS146388B,5MA161,RCF,3/17/2014,"Resident #2 started showing signs of oral pain on January 28, 2014. Resident #2 was not able to verbally communicate his/her needs but indicated signs of oral pain by grabbing face, clutching jaw and moaning. Resident #2 did not see a dentist until 3/18/14. The facility failed to obtain timely treatment for Resident #2 resulting in him/her experiencing prolonged pain and discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS135436,5MA161,RCF,12/18/2013,"Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Resident #1 and Resident #2 both have a history of negative behaviors. The facility failed to appropriately address Resident #1 and Resident #2's aggressive behaviors that had been demonstrated prior to this incident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS146818,5MA161,RCF,4/17/2014,"Resident #1 had a history of falls. Resident #1 experienced sixteen falls between 1/8/14 and 4/30/14. Some of the falls resulted in pain or skin injuries. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS147547,5MA161,RCF,6/27/2014,"Resident #1 and Resident #2 were involved in an altercation. Both residents have numerous behaviors documented. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors that had been demonstrated prior to this incident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS147962,5MA161,RCF,7/19/2014,"Resident #1 is non ambulatory and is unable to transfer on own. Resident #1 requires two staff for all transfers. Resident #1 was found to have a bruise located above his/her left eye, a small scratch on his/her right eye, and his/her left fingernail was found to be cracked all the way across the nail. Facility staff was unable to determine how the injuries occurred. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS148393,5MA161,RCF,8/14/2014,Resident #1 had a history of falls. Resident #1 experienced several falls with injury during a short period of time. The facility failed to adequately update Resident #1's service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS149251,5MA161,RCF,11/17/2014,"Reported Perpetrator 2 (RP2) put his/her colds hands on Resident #1's face. RP2 then put his/her bottom in Resident #1's face and passed gas. Resident #1 was yelling ""smell, dirty bird, rude"" over and over. RP2 was found responsible for emotional abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MS147815,5MA161,RCF,7/17/2014,Resident #1 sustained multiple skin injuries from an unknown cause. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS150378,5MA161,RCF,2/25/2015,"Resident #1 was known to exit seek and was on fifteen minutes checks. The courtyard doors were to be locked around 7:30 pm - 8:00 pm. Resident #1 was found in the courtyard at 10:40 pm. Resident #1 sustained open skin injuries to his/her feet. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS147954,5MA161,RCF,7/30/2014,Resident #1 and Resident #2 were involved in an altercation. Both residents had a history of behaviors and altercations. The facility failed to address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS151364,5MA161,RCF,5/24/2015,"Resident #1 had multiple altercations with other residents at the facility. Resident #3 sustained injury due to Resident #1 grabbing him/her. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS151580,5MA161,RCF,6/11/2015,"Resident #1 was being resistive during personal care. Reported Perpetrator 2's (RP2) tone of voice was demeaning and domineering when she/he told Resident #1 to ""knock it off"". The facility failed to assure Resident #1's rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS151416,5MA161,RCF,5/29/2015,"Resident #1 inappropriately touched Resident #2's breasts on multiple occasions. Resident #1 also grabbed Resident #3 and pulled him/her down onto Resident #1. The facility failed to appropriately care plan for Resident #1's sexual behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS151595,5MA161,RCF,6/16/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained scratches. Both residents have a history of physical behaviors toward staff and other residents. The facility failed to implement interventions to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS151715,5MA161,RCF,6/21/2015,"Reported Perpetrator 2 (RP2) assisted with showering Resident #1 and Resident #3. Both residents had a history of aggressive behaviors toward staff. Both residents were agitated at the time of their showers. RP2 sprayed both residents in the face with water to control their aggressive behaviors. RP2 was found responsible for emotional abuse. The facility + +failed to protect Resident #1 from emotional abuse. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MS152258,5MA161,RCF,7/28/2015,"Resident #2 was found in Resident #1's room. Resident #2 had scratches and a skin tear on his/her wrist and hand. Resident #1 had a history of altercations and scratching other residents and staff. Resident #2 had a history of entering others rooms and altercations. The facility failed to Implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH116926,5MA162,RCF,4/28/2011,"The Facility failed to assess and document in the service plan for resident #2_x001A_s aggressive behaviors. On the day of placing a new resident in a room with the resident #2, an altercation occurred which resulted in the new resident suffering a fractured ankle.",3,300,,,Neglect +BH117580,5MA162,RCF,7/18/2011,"The facility failed to assess and intervene in a timely manner resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH117882,5MA162,RCF,8/13/2011,"The facility failed to follow Resident #1 care plan resulting in a fall with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO12024,5MA162,RCF,3/15/2012,"The Residential Care Facility_x001A_s survey history including a relicensure survey completed on February 25, 2011 and four subsequent revisit surveys, incorporated into this notice by reference determined that the Facility continue to be out of compliance with the Oregon Administrative Rules for Residential Care and Assisted Living Facilities, and that the Facility_x001A_s noncompliance placed residents at harm and risk for serious harm.",2,0,,,Neglect +BH120066,5MA162,RCF,5/1/2012,"Resident #1 had a history of constipation and had physician's orders for medication if no bowel movement in two days. The facility failed to follow physician's orders resulting in constipation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH120275,5MA162,RCF,6/8/2012,"Resident #1 had a history of constipation and required bowel monitoring and medication intervention. The facility failed to follow bowel protocol resulting in painful bowel movement that required disimpactation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +BH132031,5MA162,RCF,12/26/2012,Resident #1 was not provided incontinence care or assisted out of bed during day shift. Reported Perpetrator 2 (RP2) stated that Resident #1 refused care but he/she did not report to his/her supervisor or document the refusal. RP2 was found responsible for neglect of care. The facility failed to assure that Resident #1 was provided with care. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Neglect +BH132238,5MA162,RCF,1/23/2013,Resident #1 and Resident #2 were agitated with each other. Resident #3 tried to intervene to calm them. Resident #1 grabbed Resident #3_x001A_s arm. Resident #3 sustained a bruise to his/her arm. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH132208,5MA162,RCF,1/7/2013,The facility failed to have a safe medication administration system resulting in Resident #1 not receiving a prescribed medication. Resident #1 did not experience any harm as a result. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO13114,5MA162,RCF,7/2/2013,"A re-licensure survey completed on July 2, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to monitor and re-evaluate skin breakdown interventions, coordinate care with outside providers, ensure physician's orders were carried out as prescribed and ensure parameters were provided for the administration of PRN medications. Resident #9 experienced a change of condition. Resident #9 had a worsening pressure ulcer. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH133337,5MA162,RCF,5/26/2013,"Residents #1 and #2 were sitting next to each other at the dining table. Resident #2 scratched Resident #1's hand when he/she reached for Resident #2's food, resulting in a skin tear to Resident #1's hand. Resident #2's Service Plan said to avoid placing him/her close to other residents at meal time. The facility failed to address Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.",2,,,, +BH146850,5MA162,RCF,4/12/2014,Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained a skin tear on his/her hand. Resident #1 had a history of altercations and was territorial. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH147442,5MA162,RCF,6/9/2014,Resident #1 was involved in three resident to resident altercations in one day. He/she had not been involved in any previous altercations. No injuries were sustained. Resident #1 was hospitalized and medication changes were made.,0,,,, +BH148310,5MA162,RCF,5/5/2014,Resident #1 was care planned as a two person transfer at all times. Reported Perpatrator 2 (RP2) was assisting him/her and Resident #1 fell. Resident #1 sustained a contusion on his/her right hip. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to follow Resident #1's care plan relating to transfers and appropriately training staff. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +BH150210,5MA162,RCF,1/2/2015,"Resident #3 had a history of altercations and aggression. Resident #3 was involved in an altercation with Resident #2 and then with Resident #1. The facility failed to implement adequate interventions regarding Resident #3's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH147603,5MA162,RCF,12/30/2013,"Resident #1 was found on the floor of his/her room with blood on his/her head. Prior to the incident it was discovered that Resident #1 needed to be repositioned in bed during the night. He/she was transported to the hospital where he/she was diagnosed with a fracture in his/her neck. The facility failed to properly plan care for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted; however, one will not be issued due to the extended period of time between the incident date and processing by the Department.",3,,,,Neglect +BH150570,5MA162,RCF,1/1/2015,"Resident #1 struck Resident #2 across the face. Resident #1 struck Resident #3 in the back of the head. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +OT116194A,5MA166,RCF,1/8/2011,"The Facility failed to implement reasonable precautions to ensure the health, safety and well-being of residents in the facility in terms of proper protocol of moving residents when falls occur. Resident #1 fell and staff responded timely; however lifted him/her back to the recliner causing unreasonable discomfort to him/her.",2,0,,,Neglect +OT116194B,5MA166,RCF,1/8/2011,Resident #1's wheelchair was moved away from him/her to prevent further attempts to self transfer and was denied bed-time before 8pm. The facility failed to excerise resident rights.,2,0,,, +NB117493,5MA166,RCF,8/30/2010,"The facility began an internal investigation on 12/10/10 that revealed numerous narcotic medication errors affecting six residents. The facility failed to ensure a safe and adequate medication system that revealed narcotic medication errors and also failed to immediately notify the local offices of law enforcement and Seniors and People with Disabilities. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +OT117896,5MA166,RCF,8/17/2011,"Resident #1 had history of exit seeking and had one prior successful exit. He/she eloped from the secured building, was gone for approximately one and a half hours, and was returned by a non facility member. The facility failed to implement interventions and provide clear direction to staff of services to provide for his/her behavior.",2,0,,, +OT129999,5MA166,RCF,4/5/2012,"Resident #1's care plan indicated he/she had difficulty following directions, was at risk for falls during ambulation and transfers, and could become agitated during care needs. On 4/5/12, Reported Perpetrator 2 (RP2) assisted Resident #1 in the bathroom, RP2 stepped away to get item and told Resident #1 to remain seated. Resident #1 fell causing a small skin tear. Reported Perpetrator 2 was neglectful in Resident #1's care. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +OT146771,5MA166,RCF,4/6/2014,"Resident #1 had cognitive impairment. He/she eloped from the facility without staff knowledge, was later found and returned without injury. It was discovered that the door was not closed completely, the backyard gate had a loose fitting latch, and that the alarm setting was set on chime (a low audible sound). The facility failed to take reasonable precautions to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,,, +OT150751C,5MA166,RCF,12/11/2012,The facility failed to ensure Resident #1's care plan was followed for staff to check his/her hearing aid daily. Resident #1's hearing aid was found with excessive wax build up which rendered the device not fully functional. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM104329,5MA170,RCF,3/1/2010,The facility failed to keep an accurate medication administration record for Resident #1 resulting in the resident not receiving a medication as ordered. The failure is a violation of OARs.,2,0,,, +MM116043,5MA170,RCF,10/7/2010,"The facility failed to appropriately monitor and intervene after resident experienced multiple falls. The last fall resulted in Resident #1 being sent to the hospital for treatment. The facility also failed to follow Resident #1_x001A_s Service Plan regarding non skid socks. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MM105948,5MA170,RCF,11/18/2010,"The facility failed to obtain a pain medication and a physician in a timely manner resulting in unreasonable discomfort that required transportation to the hospital for treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MM105782,5MA170,RCF,11/23/2010,"The facility failed to adequately care plan after Resident #1continued to experience multiple falls with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM105921,5MA170,RCF,12/8/2010,"Resident #1 had access to, and attempted to consume a liquid product that was supposed to be secured after staff use. The facility failed to provide a safe environment resulting in the potential for harm to Resident #1.",2,0,,, +MM116111,5MA170,RCF,11/1/2010,Multiple discrepancies were observed on several residents' MARs (front and back) and their narcotic records. RP2's initials were documented as the person who made the errors and was terminated from employment. The facility failed to provide a safe medication administration system resulting in the potential for harm to all residents.,2,0,,, +MM116212,5MA170,RCF,1/20/2011,Resident #1 had a history of aggressive behavior prior to moving in to the facility. The facility failed to adequately care plan Resident #1's behaviors resulting in negative behavior affecting others.,2,0,,, +MM116236,5MA170,RCF,1/21/2011,"Resident #1 had a history of falls and was service planned for one person assist. Resident #1 fell down at the nurse's station without a one person assist and fractured wrist. The facility failed to follow the service plan resulting in moderate harm to Resident #1. A sanction is warranted, however not issued due to the facility that the facility entered into a written agreement in lieu of a license condition on May 2, 2011.",3,0,,,Neglect +MM116160A,5MA170,RCF,12/30/2010,The facility failed to provide appropriate resident services resulting in inadequate hygiene. Resident #1 was observed with feces under nails on two occasions. The failure is a violation of OARs.,2,0,,, +MM116160B,5MA170,RCF,12/30/2010,The facility failed to provide a safe medication administration record resulting in the loss of Resident #1's narcotic medication card to another resident's family. The medication error was discovered and fixed prior to the need to administer the medication to Resident #1. The failure is a violation of OARs.,2,0,,, +MM116491,5MA170,RCF,3/6/2011,"A resident of the Facility began experiencing falls after admitting. While the Facility assessed the resident as being at risk for falls, the Facility did not put needed interventions in place to reduce the likelihood of additional falls, resulting in the resident continuing to fall. The resident was found to have fallen, but was put back in bed. During the next check of the resident he/she was found to be non-weight bearing on his/her foot and was transported to a medical facility where it was determined that he/she suffered a fracture to his/her ankle.",3,0,,,Neglect +MM116774,5MA170,RCF,11/20/2010,The facility failed to provide a safe medication administration resulting in Resident #1 receiving the wrong dose of medication on one occasion and ingesting another resident's ensure that contained medication. There was no harm as a result of the medication errors. The failures are violations of OAR.,2,0,,, +MM116873,5MA170,RCF,4/16/2011,"Resident #1 and Resident #2 had a history of aggressive behavior. Resident #2 was agitated on April 16, 2011 after returning to the facility and had a history of being agitated when family returns the resident to the facility. Resident #2 was upset and yelled and hit Resident #1. The facility failed to address Resident #2's behavior and provide interventions in her/his service plan. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,0,,,Neglect +MM117132B,5MA170,RCF,5/18/2011,"On May 17, 2011, RP2 attempted to assist Resident #2 with incontinence care when the resident refused. RP2 continued to assist Resident #2 when the resident got agitated and pushed RP2. Resident #2 was observed with bruising the following day. The investigative was unable to determine if the bruising was caused during this incident.",0,0,Not Substantiated,Substantiated,Neglect +MM117635,5MA170,RCF,7/25/2011,"Resident #1 choked Resident #2 in the dining room. The facility failed to address and care plan RV2's behaviors resulting in agitating RV1 and being choked until staff intervened. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117769B,5MA170,RCF,8/11/2011,"Resident fell multiple times and the facility did not put interventions in place in a timely manner. The facility failed to appropriately care plan for falls resulting in fall with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM118129,5MA170,RCF,9/23/2011,"Resident #1 had a history of falls prior to being admitted to the facility. The facility failed to adequately care plan for falls resulting in a fractured hip. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty was warrented, however not issued due to the License Condition issued on November 17, 2011.",3,0,,,Neglect +MM118172,5MA170,RCF,10/1/2011,"This matter was remanded back to the agency for redetermination on the issue of ""self-defense"" with respect to the determination of substantiated abuse by RP2, pursuant to Multnomah County circuit court case No. 120505461. After reconsidering the matter as directed by the court, the department issues this amended Letter of Determination. + +Resident #1 had a diagnosis related to cognition issues and had a care plan to deal with his/her occasionally combative behaviors. On or about October 1, 2011, RP2 physically harmed and was verbally inappropriate with Resident #1 after Resident #1 became combative when RP2 initiated resident personal care. RP2 asserts RP2 grabbed Resident #1's wrist to stop Resident #1 from physically striking RP2, causing skin discoloration and a skin tear to the resident in the process. + +Physical abuse is defined under OAR 411-020-0002(1)(a)(A) to include: (i) ""The use of physical force that may result in bodily injury, physical pain, or impairment or (ii) Any physical injury to an adult caused by other than accidental means."" Nowhere within this rule, or any other rule relating to the determination of abuse, is ""self defense"" specifically addressed. However, the department does examine the totality of circumstances when reviewing an incident to determine whether to substantiate a finding of abuse. + +In this case, RP2 knew that Resident #1 had a history of combative behavior, but failed to heed the resident's multiple requests to leave him/her alone. RP2 continued to engage with the resident, resulting in increased agitation and combative behavior by the resident. RP2's conduct was contrary to the resident's care plan. Although it may be that the resident became combative toward RP2, RP2 could have simply blocked the strikes from the resident. This altercation did not justify the use of any physical force to the resident. RP2 was not in imminent danger that might have required the use of physical force for the resident's safety or for the safety of others. RP2 had the ability to step away from the resident and be on standby mode if resident safety was a concern. From that position, RP2 could have also continued to request assistance from other staff. RP2 had multiple options to protect himself/herself from the resident's combative behavior without using physical force against the resident. Based upon the totality of the circumstances, RP2 was not justified in causing physical injury to Resident #1. Therefore, RP2 is substantiated for physical abuse. + +The facility was aware of RP2's inability to work with residents with combative behaviors. The facility failed to ensure a safe environment resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,Substantiated,Substantiated,Physical Abuse +MM117591B,5MA170,RCF,7/1/2011,"The facility failed to investigate injury of unknown origin after Resident #2 was discovered with bruises on upper harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117874A,5MA170,RCF,8/19/2011,"Resident #1 was admitted to the facility without signed physician orders. The facility failed to administer Resident #1's medications resulting in being transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM117874B,5MA170,RCF,8/19/2011,"Resident #1 had a history of aggressive behavior. The facility failed to address Resident #1's aggressive behavior prior to admittance to the facility resulting in negative behavior that required outside treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM118173,5MA170,RCF,8/8/2011,"Resident #1 developed a Stage IV decubitus ulcer. The facility failed to provide appropriate oversight and monitoring. Facility failed to timely update Resident #1's Service Plan to address current condition and provide directions on wound treatment. The failures are violations of resident rights, are considered nelgect of care and constitute abuse.",3,300,,,Neglect +MM117911B,5MA170,RCF,9/3/2011,RP2 wrote an unauthorized physician order that staff administered to Resident #2 resulting in the potential for harm.,2,0,,, +MM118293B,5MA170,RCF,10/20/2011,"Resident #2 had multiple falls, some resulting in bumps and bruises. Facility documentation revealed 6 falls occurred prior to attempting new interventions. The facility failed to timely address Resident #2's falls resulting in falls with injury.",2,0,,,Neglect +MM118575,5MA170,RCF,11/24/2011,The facility failed to appropriately address and intervene after Resident #1 and Resident #3 continued to have aggressive behaviors. A license condition was issued in November 2011 related to resident to resident issues.,2,0,,,Neglect +MM118517,5MA170,RCF,11/20/2011,Resident #1 had a condition that required constant monitoring to ensure she/he only drank liquids high in sodium. RP2 physically restrained Resident #1 to prevent from drinking coffee until another staff member came to assist. The facility failed to ensure Resident #1's Service Plan was followed resulting in minor harm. RP2 was not held responsible for abuse.,2,0,,,Neglect +MM118758A,5MA170,RCF,12/13/2011,"Resident #1 was identified by an outside medical facility to have lost weight and physician ordered a specific diet that included 2 supplemental house shakes twice a day. The facility failed to monitor Resident #1_x001A_s weight and ensure physician_x001A_s orders were being followed resulting in a significant weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +MM118758B,5MA170,RCF,12/13/2011,"Resident #1 resided in a memory care facility with a diagnosis related to cognitive impairment. Resident #1 had a history of attempting to self ambulate. The facility failed to adequately care plan related to falls resulting in numerous falls with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,0,,,Neglect +MM118759A,5MA170,RCF,12/13/2011,"Resident #1 wandered into Resident #2's room resulting in a physical altercation. Resident #1 and Resident #2 had a history of altercations and care planned to keep separated. Resident #1 also had a history of wandering into other residents' room and care planned to keep out of residents' personal space. The facility failed to follow Resident #1 and #2's service plans resulting in minor harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM118759B,5MA170,RCF,12/13/2011,Resident #1 was observed with substance in and around her/his mouth that was later identified as barrier cream. A tube of barrier cream was found in another resident's room. Resident #1 was sent to the hospital as a precaution and monitored with no observable negative outcome. The facility failed to ensure medications were secured in a locked area when not in use resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM128988,5MA170,RCF,1/5/2012,"On two separate occassions, it was suspected that RP2 may have physically harmed residents. Resident #1 and Resident #2 have a condition related to memory impairment and were unable to recall events. It is unable to be determined if residents were hit by RP2. Witness testimony revealed RP2 was observed to be impatient and verbally disrespecful to residents. RP2 was put on administrative leave. The facility failed to assure residents were treated with dignity and respect. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM129472,5MA170,RCF,3/8/2012,"On or about March 8, 2012, Resident #1 fell and dislocated her/his hip. Resident #1 was discharged from the hospital with orders to wear a knee brace at all times. On March 9 and 10, 2012, Resident #1 was found without her/his knee brace on. On March 10, 2012, Resident #1 complained of severe left hip pain and observed with a swollen hip. Resident #1 was transported to the hospital and admitted. Documentation indicated that the resident required hip replacement. The facility failed to appropriately monitor to ensure physician orders were followed, contributing to her/his medical condition worsening. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +MM129307,5MA170,RCF,1/15/2012,"Resident #1 had a history of aggressive behavior when others are in close proximity to her/his personal space. On four known occasions, residents entered Resident #1's personal space resulting in aggressive behavior. The facility failed to appropriately care plan resulting in altercations. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +MM129525,5MA170,RCF,2/25/2012,"Resident #1 was observed to repeatedly yell and call Resident #2's derogatory names throughout the day causing Resident #2's agitation to escalate and engage in a physical altercation with Resident #1. The facility failed to follow the residents' care plan resulting in an unnecessary altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +MM129757,5MA170,RCF,4/4/2012,Resident #1 had a medical diagnosis that required one on one monitoring and fluid restrictions. Resident #1 was left alone in the bathroom where she/he drank water out of the toilet. The facility failed to follow physician's orders and care plan resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM120130,5MA170,RCF,5/18/2012,"Resident #2 had a history of wandering and aggressive behavior. On or about May 18, 2012, Resident #1 was struck in the chest after attempting to remove Resident #2 from her/his room. The facility failed to appropriately care plan to address Resident #2's behavior resulting in minor harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +MM121211,5MA170,RCF,8/28/2012,The facility failed to provide a safe environment resulting in the successful elopement of Resident #1. Resident #1 eloped through an unsecure gate and was later returned unharmed after discovered wandering at a local school. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM121218,5MA170,RCF,8/23/2012,"Resident #2 was admitted to the facility with known aggressive behaviors. Resident #2 experienced aggressive behaviors with other residents on August 18 and 19, 2012. On August 22, 2012, Resident #2 was physically aggressive with Resident #1 requiring transportation to the hospital for an evaluation. The facility failed to appropriately care plan Resident #2's aggressive behavior, failed to conduct a timely and appropriate internal investigation, and failed to report the incident. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +MM120636A,5MA170,RCF,7/12/2012,"Resident #1 was admitted to the facility in July 2012 with a history of taking as needed medication on a routine basis. Resident #1 requested and did not receive her/his medication to aide in sleep as requested in the month of July. Resident #1 began exhibiting behaviors. The facility failed to follow up with the physician on changing medications to routine basis after the customary routine prior to admittance was identified and requested. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO13037,5MA170,RCF,2/8/2013,Please see RCFCD13-005 document for specific details.,3,0,,,Neglect +MM121982,5MA170,RCF,12/24/2012,"Resident #2 had increased agitated and aggressive behaviors. On or about December 24, 2012, Resident #2 hit Resident #1 in the groin. The facility failed to adequately address Resident #2's behavior and provide clear direction on her/his service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM132038A,5MA170,RCF,1/1/2013,"Resident #1 exhibited agitated and aggressive behaviors. Care staff requested medication to treat behavior but none were provided. Resident #1's agitated behavior increased resulting in aggressive behavior towards care staff. RP2 responded with an inappropriate verbal comment. The facility failed to ensure Resident #1's behavior was appropriately addressed resulting in loss of dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 was not held responsible for abuse.",2,0,,,Neglect +MM132038B,5MA170,RCF,1/1/2013,"Resident #1 has a history of agitated and aggressive behavior. The facility failed to appropriately care plan and provide clear directions on how to deal with Resident #1's behaviors resulting in increased aggression and agitation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM121387,5MA170,RCF,10/15/2012,It was reported that RP2 was heard yelling and cursing while in Resident #1's room. The facility failed to ensure resident rights resulting in loss of dignity. The failure is a violation of Oregon Administrative Rules. RP2 was not held responsible for abuse.,2,0,,, +MM132070,5MA170,RCF,12/8/2012,"Resident #1 was admitted to the facility on December 8, 2012, ambulatory and with a diagnosis of dementia. Resident #1 experienced agitated and aggressive behaviors resulting in harm that required transportation to the hospital for treatment and medication changes. Resident #1_x001A_s behaviors continued and began experiencing multiple falls. The facility failed to conduct RN assessment, provide interventions and adequately care plan on significant changes of conditions related to behaviors and falls. The facility failed to provide a safe medication administration system resulting in receiving as needed medication on a routine basis. Resident #1 experienced sedation and multiple falls. On January 4, 2013, Resident #1 was transported to the hospital in respiratory distress and diagnosed with respiratory failure and sepsis due to pneumonia, dehydration and acute renal failure. Resident #1 passed away on January 18, 2013. The facility failed to appropriately monitor including food and fluid intake. The failures are violations of resident rights, are considered neglect of care and constitute abuse. RP2 was also found responsible for neglect of care and constitutes abuse.",4,2500,Substantiated,Substantiated,Neglect +MM132424,5MA170,RCF,2/8/2013,"Resident #1 had a history of aggressive behavior. The facility failed to adequately address Resident #1_x001A_s aggressive behavior and provide a safe environment resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitues abuse. A civil money penalty was warranted, but not issued due to an Order Imposing License Condition issued on April 5, 2013.",2,0,,,Neglect +MM133000,5MA170,RCF,4/5/2013,Resident #1 had a new order for pain medication on 4/5/2013. The medication was not given as ordered at 2pm.,2,0,,, +MM132329,5MA170,RCF,1/15/2013,RP2 was verbally abusive towards Resident #1 and Resident #2. RP2 and RP3 shone flashlights into Resident #2's room for the purpose of causing emotional harm. Resident #2 had a negative reaction to the flashlights. RP2 and RP3 were found to be emotionally abusive towards Resident #2. The facility failed to prevent verbal and emotional abuse towards Resident #1 and Resident #2. The failures are violations of Oregon Administrative Rules. RP2 and RP3 have been found responsible for emotional abuse. RP2 has also been found responsible for verbal abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MM133301,5MA170,RCF,5/22/2013,"Resident #2 had a history of agitated behavior and care planned to keep separate during meal time and activities. The facility failed to follow Resident #2's service plan resulting in a resident to resident altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty was not issued due to the ongoing license condition at the facility.",2,,,,Neglect +MM133336,5MA170,RCF,5/27/2013,"On or about May 27, 2013, the facility discovered two residents with bruises. A facility-wide skin audit revealed an additional four residents had bruising also. It was discovered that staff were not conducting skin audits. The facility failed to appropriately monitor resulting in bruising of unknown origins. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM121539,5MA170,RCF,11/3/2012,"The facility managed Resident #1's medication. Resident #1 had an order for a medication that was identified as to not stop administering abruptly. The facility ran out of Resident #1's medication on or about October 29, 2013. Facility did not follow up with Resident #1's family and the resident did not receive the medication for approximately 6 days. Resident #1 was eventually taken to the hospital by Witness #1 to get a refill. The facility failed to provide a safe medication administration system resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to the current license condition and intent to revoke issued on or about April 5, 2013.",3,,,,Neglect +MM132491,5MA170,RCF,2/18/2013,"On or about February 18, 2013, there was a physical altercation between Resident #1 and Resident #2. Resident #1 had a prescribed medication for agitation that was not administered between January 2 and January 30, 2013. Facility documentation and witness testimony revealed Resident #1 had a history of increased agitated and aggressive behavior. The facility failed to provide a safe environment. The facility also failed to administer medication as ordered. The failures are violations of resident rights, are considered neglect of care and constitute abuse. An order imposing license condition and intent to revoke residential care facility license was issued on or about April 5, 2013.",2,,,,Neglect +MM134568,5MA170,RCF,9/26/2013,Resident #1 had a history of negative behavior affecting other residents. The facility failed to appropriately care plan resulting in continued negative behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM146419,5MA170,RCF,3/22/2013,Complainant reported that the facility has not responded to transferring Resident #1's PIF account since she/he moved to another facility a year ago. Investigation was initiated and a transfer of the funds was completed. The facility failed to provide PIF funds in a timely manner and is a failure of Oregon Administrative Rules.,2,,,, +MM148537,5MA170,RCF,8/29/2014,"The facility failed to ensure a safe environment resulting in Resident #1 leaving the secure building. Resident #1 was found in the brush nearby and treated for scratches prior to returning to the facility. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM148370,5MA170,RCF,8/29/2014,"Resident #1 had a diagnosis related to memory impairment and resided in a secure memory care facility. Resident #1 was discovered outside of the facility in a ditch with minor injuries. An internal investigation was initiated and determined that the resident more than likely followed a visitor out the front door. The facility failed to ensure a safe and secure environment resulting in minor harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM147206,5MA170,RCF,5/22/2014,"The facility failed to administer Resident #1's anti-siezure medication. Resident #1 missed three doses of their medication and had two seizures. This failure is considered neglect of care, constitutes abuse, and violates Oregon Administrative Rules.",2,,,,Neglect +MM148782,5MA170,RCF,9/25/2014,"The facility failed to follow Resident #1's care plan and check Resident #1 every 2 hours. Resident #1 sustained an unwitnessed fall with bruising to the face and hand. This failure is a considered neglect of care, which constitutes abuse, and is a violation or Oregon Administrative Rules.",2,,,,Neglect +MM148336,5MA170,RCF,8/26/2014,"The facility failed to provide a safe environment in relation to a resident to resident altercation. Resident #2 had a history of aggression towards other residents. Resident #2 grabbed Resident #1's arm causing a bruise. This failure is considered neglect of care, which is abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +SV105829,5MA205,RCF,12/2/2010,A resident of the Facility suffered a fall with injury following receiving dressing assistance from a Facility staff member. The staff member did not ensure the resident's slacks were pulled up all the way. The resident attempted to ambulate and sustained a fall.,2,0,,,Neglect +SV105957,5MA205,RCF,12/20/2010,"A resident of the Facility was receiving assistance with dressing when a staff member left the resident to obtain items for the resident to wear. The staff member requested the resident ambulate to his/her bathroom. Upon doing so, the resident experienced a fall with injury. The resident did not have on the proper footwear at the time.",2,0,,,Neglect +SV116764,5MA205,RCF,4/13/2011,"A newly admitted resident to the Facility was noted to have experienced a fall with injury while in another resident's room. It was not conclusive what caused the resident to fall, as neither resident was able to provide a clear account of what occurred. Following the fall, Facility staff did not follow Facility protocol with respect to responding to the situation.",2,0,,, +SV105094,5MA205,RCF,8/12/2010,The Facility failed to implement an intervention put in place earlier in the day with respect to a residents fall risk. The resident suffered a non-injury fall later that day.,1,0,,, +SV105093,5MA205,RCF,8/10/2010,The facility failed to administer medication as ordered resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +SV118069,5MA205,RCF,9/22/2011,RP2 was assisting Resident #1 with getting up for the day. He/she left Resident #1 to get assistance and did not follow service plan by placing pillow roll under mattress. Resident #1 fell out of bed and sustained injury.,3,0,Not Substantiated,Substantiated,Neglect +SV105250,5MA205,RCF,9/12/2010,"Resident #1 fell out of bed onto the floor and sustained a bruise to his/her forehead. As part of Resident 1_x001A_s care plan, a fall mat is to be placed beside the bed whenever Resident #1 is sleeping. The fall mat was not placed beside the bed. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +SV129344,5MA205,RCF,2/23/2012,Resident #1 and Resident #2 were involved in an altercation. This was the first incident between Resident #1 and Resident #2. Facility staff intervened appropriately.,0,0,,, +MV120690,5MA205,RCF,6/21/2012,"Resident #1 eloped from the facility on June 21, 2012. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO12098,5MA205,RCF,8/28/2012,,3,0,,,Neglect +MV120650A,5MA205,RCF,7/21/2012,"Resident #1 and Resident #2 were involved in six altercations involving other residents and each other in a two month period. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors resulting in physical altercations, some involving injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty, however, due to the fact that the facility if on a current condition (RCFCD12-003) a civil penalty will not be issued.",3,0,,,Neglect +MV120650B,5MA205,RCF,7/21/2012,"Resident altercations from May 31, 2012, through July 21, 2012, for a total of six were not reported to APS. The facility failed to report potential or suspected abuse. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV120947,5MA205,RCF,8/29/2012,Resident #1 alerted staff at 9:45 a.m. that he/she was ready to get up. Staff did not respond to Resident #1 until 10:30 a.m. Resident #1 was found on the floor in his/her bathroom with injuries. Resident #1 was sent to the hospital for evaluation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV121077,5MA205,RCF,9/14/2012,"Resident #1 had five incidents of aggression toward other residents in the month of September. No updates or interventions were added to his/her service plan to address Resident #1_x001A_s aggressive nature. Resident #3 has been involved in three of the incidents and no updates to care plans have been made to keep Resident #1 and Resident #3 separated. The facility failed to address Resident #1_x001A_s behaviors. Due to the facility_x001A_s history, the failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility is on a current condition (RCFCD12-003) a civil penalty will not be issued.",3,0,,,Neglect +MV121535,5MA205,RCF,10/25/2012,Resident #2 was involved in five resident altercations during a short period of time. The facility failed to address Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrate Rules.,2,0,,, +MV129818,5MA205,RCF,4/10/2012,"Resident #1 eloped from the facility on April 10, 2012. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV120784,5MA205,RCF,8/1/2012,Resident #1 and Resident #2 were involved in an altercation. Resident #1 sustained a split lip. Both residents have been involved in previous altercations with other residents. The facility failed to address Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV129816,5MA205,RCF,4/8/2012,Resident #1 and Resident #2 were involved in an altercation. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV132526,5MA205,RCF,11/28/2012,Resident #1 and Resident #2 were involved in an altercation. Resident #1 sustained a split lip. The facility failed to address Resident #1 and Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV132265,5MA205,RCF,11/1/2012,It was reported that Resident #1 was missing his/her wedding rings. Witness #1 had reported the missing rings to the previous administrator and was told that a report had been made to APS. Months later Witness #1 inquired about the missing rings to the new administrator. No report had been made to APS. An unknown individual was responsible for the loss of Resident #1_x001A_s rings. The facility failed to provide a safe environment and report the incident to APS when it was first reported by Witness #1. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MV121719,5MA205,RCF,11/26/2012,It was discovered that resident PIF funds were missing from the safe. The facility replaced all missing resident funds. An unknown individual was responsible for the loss of money which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MV121743,5MA205,RCF,10/23/2012,"Resident #1 has been involved in physical altercations with Resident #2, #3, #4 and #5. No injuries were incurred in any of the incidents. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV118654B,5MA205,RCF,11/29/2011,"Resident #1 fell on his/her buttocks on 10/14/11 and 11/08/11. No injuries were noted at the time. Progress notes on 11/08, 11/12 and 11/13 reflect Resident #1 complaining of pain, walking with a tilt, refusing to get out of bed due to pain and screaming each time staff moved him/her. There was no documentation of an assessment of Resident #1 until 11/15/11, when a wound to his/her buttocks was discovered. By 11/29/11, Resident #1 was transferred to the emergency room with a stage three decubitus ulcer. The facility failed to provide proper care to Resident #1. The failure is a violation of resident rights, is considered neglect and constitutes abuse. The Notification of Findings was completed at a later date; therefore a civil penalty was not issued due to the extended period of time between the incident date and processing by the Departments.",4,,,,Neglect +MV120713A,5MA205,RCF,5/1/2012,The facility received a list of Resident #1's medications from his/her physician. The facility misread the corrections/changes and discontinued two prescriptions. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV120713B,5MA205,RCF,5/1/2012,It was reported to the facility that Resident #1_x001A_s clothing and sheets kept coming up missing. The facility did not replace the items and there is no indication that the facility took any action. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV120713C,5MA205,RCF,5/1/2012,It was reported that the facility failed to provide proper care to Resident #1. Witness #3 was concerned that the cord holding Resident #1's keys and name tag was a choking hazard. There was no indication that the facility took any action. Witness #3 replaced the cord with a break away lanyard. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV134477,5MA205,RCF,8/28/2013,A narcotic pain patch was ordered and delivered for Resident #1 between 11 p.m. and 1:00 a.m. Resident #1 did not receive the patch until around 8:00 a.m. the next morning. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV147620,5MA205,RCF,6/30/2014,"Resident #1 sustained a skin tear that was not reported or documented. The wound was wrapped with gauze. Witness #3 removed the bandage to find a large wound. Resident #1 was sent to the hospital for stitches. The facility failed to provide appropriate training to staff regarding injuries from an unknown cause and reporting. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV132527,5MA205,RCF,12/11/2012,Resident #1 was found in the courtyard wet and muddy. No physical injuries were found. Between 7:30 pm and 8:15 pm staff were on break and Resident #1 was not discovered in the courtyard until the Med Aide went to administer his/her medications. Resident #1's service plan states that staff are to check him/her every fifteen minutes. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV148820,5MA205,RCF,9/19/2014,"Resident #1 was a two-person transfer with a Hoyer Lift and total assist with all activities of daily living. He/she was sent to the hospital twice due to knee swelling and pain, resulting in x-rays that showed a fractured right knee. The facility failed to provide a safe environment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV148447,5MA205,RCF,9/4/2014,"Resident #1 and Resident #2 were found in the common area engaged in a sexual activity. Resident #1 had previous inappropriate sexual behaviors. The facility failed to appropriately care plan and implement interventions regarding Resident #1's inappropriate sexual behaviors. + +The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV148696,5MA205,RCF,9/19/2014,"Resident #1 was walking with Resident #2 and became agitated when staff tried to redirect Resident #2. Resident #1 wrapped his/her arm around Resident #2 causing him/her to fall. No injuries were sustained. Resident #1 had previous inappropriate behaviors, including inappropriate sexual behaviors. The facility failed to appropriately care plan and implement interventions regarding Resident #1's inappropriate behaviors and sexual behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV148949,5MA205,RCF,10/10/2014,"Resident #1 was transported to the hospital twice on the same day due to injury falls. The hospital physician stated Resident #1 was dehydrated which caused him/her to be overmedicated. The facility failed to assess Resident #1 for a change of condition and provide appropriate care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV149438C,5MA205,RCF,6/7/2014,Resident #1 required assistance with preparing for a trip to the hospital to obtain a urine sample. He/she arrived at the hospital with dried feces on his/her genital area. Hospital staff had to clean Resident #1 before they could do their treatment. The care plan stated he/she required no bathroom assistance. The facility failed to appropriately plan care for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV149334,5MA205,RCF,10/1/2014,"The facility failed to provide proper care for Resident #1. Follow-up podiatry services appointments for Resident #1 were not made by the facility. Resident #1_x001A_s feet were not monitored or evaluated resulting in an infection and ingrown toe nails. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV145832,5MA205,RCF,1/10/2014,"Facility staff and volunteer's lunches for outings were paid for using resident funds. A witness statement indicated the facility had been doing this for approximately three years. The facility failed to protect residents from misappropriation of resources. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +MV151856,5MA205,RCF,7/3/2015,"The facility failed to adequately monitor Resident #1. Resident #2 was pushed over onto the ground by Resident #1. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MV153429,5MA205,RCF,10/31/2015,"The facility failed to adequately implement interventions to reduce Resident #1's aggressive behaviors. Resident #1 punched and kicked Resident #2 when Resident #1 thought Resident #2 was in his/her spot. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +OT134657,5MA206,RCF,6/28/2013,"Upon admission to the facility, Resident #1's progress notes identified Witness 2 (W2) as a companion with whom Resident #1 had an on-going relationship. During a two month period there were multiple instances in which Resident #1 was not able to visit with W2 due to stated or implied requests from a family member. Resident #1 was capable of making his/her own decisions and did not have a legal guardian. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB105674,5MA207,RCF,11/14/2010,"Resident #1 and Resident #2 had a physical altercation in which Resident #1 sustained minor injury to her/his arm. Resident #1 had a previous incident. The facility failed to provide a safe environment and update Resident #1's service plan resulting in minor harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB117379,5MA207,RCF,7/2/2011,"Resident #1 had a previous history of inappropriate sexual behavior. Resident #2 was observed with hands up Resident #1's shirt. The facility failed to protect Resident #1 from inappropriate sexual contact. The failure is a violation of resident rights, is considered neglect of care and constitutes sexual abuse.",2,0,,,Sexual abuse +HB133370,5MA207,RCF,6/3/2013,"Resident #1 had a history of exit seeking and attempting to follow others out the front door of the facility. He/she was care planned for monitoring in common areas. Resident #1 followed a visitor out of the building, was found wandering fifteen minutes later and returned to the facility without injury. The facility is next to a four-lane divided highway. The facility failed to follow the care plan. The failure is a violation of resident's rights, which is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB133960,5MA207,RCF,7/29/2013,"Resident #1 and Resident #2 had a history of aggressive behaviors. Resident #1 experienced mulitple physical altercations with other residents. The facility failed to adequately monitor and care plan resulting in continued resident to resident altercations. The failures are violations of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB134241B,5MA207,RCF,8/27/2013,"Resident #1 had a routine and prn (as needed) prescribed sleep medications. The facility failed to follow the care plan and failed to follow physician orders resulting in Resident #1 experiencing sleep disturbances for three days. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB148092,5MA207,RCF,8/11/2014,"Resident #1 recently moved into a secure memory care facility and was identified as an elopement risk. On or about August 11, 2014, Resident #1 eloped from the facility and was returned safely by local law enforcment. Internal investigation determined that the resident most likely left with EMTs that were there for another resident. The facility failed to ensure a safe environment resulting in the potential for harm and is a violation of Oregon Administrative Rules.",2,,,, +HB148201,5MA207,RCF,8/19/2014,Resident #1 was discovered outside the secure memory care community and it was determined that she/he was able to elope through her/his bedroom window. The window on the alarm was not functioning at the time of the incident. The facility failed to ensure a safe environment resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB151778,5MA207,RCF,6/23/2015,"On or about June 23, 2015, Resident #1 fell and sustained a broken arm. Incident report revealed a new plan in place for staff to lock arms or hold hands with the resident when ambulating. On June 26, 2015, Resident #1 fell a second time while independently walking next to Witness #3. The facility failed to update the resident's care plan and monitor resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC116128,5MA213,RCF,12/19/2010,The facility failed to have documented interventions for Resident #1's and Resident #2's behaviors to keep them safe.,2,0,,, +BC116113A,5MA213,RCF,12/7/2010,The facility failed to follow the care plan for one-on-one staffing with Resident #2 resulting in an altercation with another resident.,2,0,,, +BC116113B,5MA213,RCF,12/7/2010,The facility failed to adequately care plan related to Resident #2's aggression and falls.,2,0,,, +BC116113C,5MA213,RCF,12/7/2010,The facility failed to complete an internal investigation of Resident #2's aggression toward other residents and his/her falls.,2,0,,, +BC116113D,5MA213,RCF,12/7/2010,The facility failed to notify injuries and resident-to-resident altercations to Adult Protective Services.,2,0,,, +BC118600,5MA213,RCF,11/28/2011,"Reported Perpetrator 2 (RP2) left Resident #2's medication cup on a table in the dining room where he/she normally sits; although Resident #2 was not there. Resident #1 was found at the table with the empty medication cup in her hand, and later suffered vomiting. RP2 failed to safely administer medications and observe Resident #2 ingest his/her medications.",2,0,Not Substantiated,Substantiated,Neglect +BC120886,5MA213,RCF,8/18/2012,Reported Perpetrator 2 (RP2) failed to provide respect and dignity to Resident #1 when RP2 did not reapproach to provide care to Resident #1 when he/she became agitated. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121528,5MA213,RCF,9/8/2012,"Resident #1 had physician's orders that he/she was not to consume concentrated sweets or dairy. On 9/8/12, he/she ate two containers of pudding while unsupervised and the pudding contained dairy and sugar. Resident #1 suffered upset stomach and indigestion. The facility failed to follow physician's orders resulting in harm to Resident #1. The facility failed to report the incident to APS and conduct an internal investigation as required. The failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",2,0,,,Neglect +BC159958,5MA213,RCF,12/15/2014,"Resident #1's two rings were taken off his/her hand, which were very tight and not easily removable. His/her fingers had bruising where the rings were taken off. Reported Perpetrator 2 (RP2) admitted that he/she took Resident #1's rings. RP2's actions are considered theft by financial exploitation which constitutes abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BC151180,5MA213,RCF,5/3/2015,"It was reported that Resident #1's three rings were missing and were valued at approximately $300. An unknown individual is responsible for the theft of Resident #1_x001A_s rings, which constitutes financial exploitation. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +NB105688,5MA215,RCF,11/18/2010,"Resident #2's un-addressed increased night-time behaviors resulted in an incident between him/her, Witness #9 and Resident #1, causing another staff person to leave his/her unit with out staff to provide assistance. The facility failed to provide a safe environment and appropriate staffing levels in each unit, and failed to assess Resident #2_x001A_s behaviors.",2,0,,, +NB116420,5MA215,RCF,2/14/2011,"Reported Perpetrator 2 did not follow the care plan for Resident #1, Resident #3 and Resident #4. Resident #3 sustained a bruise on his/her wrist from dressing and care provided by RP2.",2,0,Not Substantiated,Substantiated,Neglect +NB118528,5MA215,RCF,11/23/2011,"Resident #1's toe nails were found to be very long, curved and discolored. The facility failed to care plan and provide toe nail care. These failures are a violation of Oregon Administrative Rules.",2,0,,, +NB120633,5MA215,RCF,7/26/2012,"The facility failed to follow treatment orders for Resident #1's skin breakdown and wounds resulting in his/her condition worsening. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NB121875,5MA215,RCF,12/13/2012,"The facility failed to administer medications as ordered from Resident #1's physician resulting in his/her aggressive behavior to escalate. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NB132010,5MA215,RCF,1/2/2013,"Resident #1 was given medication intended for Resident #2, and he/she experienced nausea and lethargy. Resident #2's behaviors increased as a result of not getting his/her medication. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NB132773,5MA215,RCF,3/21/2013,Resident #1 was not administered his/her morning medications on 3/21/13. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +NB133152,5MA215,RCF,5/7/2013,"Resident #1's Tubi Grips were not removed in the evening. They were left on all night. Resident #1 sustained swelling and pain in his/her legs due to TubiGrips not being removed per the service plan. The facility failed to follow Resident #1's service plan resulting in pain and swelling of his/her lower legs. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NB133028B,5MA215,RCF,4/19/2013,"Resident #1 did not receive a prescribed medication from April 4th - April 18th, 2013. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +NB133028A,5MA215,RCF,4/19/2013,"It was reported Resident #1 was found with bruises on his/her upper left arm. Staff scheduling revealed Reported Perpetrator 2 (RP2) was working during the shift the bruising reportedly took place and although there was another worker; they did not assist with Resident #1 at that time. RP2 had been counseled twice before for not using a gait belt and incorrectly transferring residents. The facility failed to provide a safe environment. The failure is a violation of resident's rights, is considered neglect and constitutes abuse. RP2 was responsible for incorrectly transferring Resident #1, which is considered neglect and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +NB133583,5MA215,RCF,6/21/2013,"On 6/12/13, Resident #1 was ordered to have antibiotics and home health started; however he/she did not receive either. On 6/21/13, he/she was ordered antibiotics again; however he/she did not receive it. Resident #1 was transported to the hospital for treatment. The facility failed to provide a safe medication administration system and failed to ensure home health services. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +NB133227,5MA215,RCF,5/14/2013,Reported Perpetrator 2 (RP2) sprayed Resident #1 in the face with water during shower assistance. Resident #1's eye and face was red and he/she was agitated after the incident. RP2 is found responsible for physical abuse towards Resident #1. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +NB134078,5MA215,RCF,8/9/2013,"The facility to appropriately address Resident #2's behaviors and failed to implement interventions to ensure resident safety. Resident #2 slapped and pushed Resident #1 down. The facilities failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +NB134387,5MA215,RCF,9/10/2013,"Resident #1 and Resident #2 had a physical altercation. Resident #2 had history of being physically aggressive with other residents and Resident #1 had history of being aggressive with staff when receiving care. The facility failed to implement interventions to address behaviors and failed monitor to ensure resident safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB134319,5MA215,RCF,9/3/2013,"Resident #3 had a physical altercation with Resident #2 and Resident #1. Resident #3 had exhibited some aggressive behaviors prior to this incident. The facility failed to implement interventions and monitor to ensure resident safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB134940,5MA215,RCF,11/5/2013,Reported Perpetrator 2 (RP2) was witnessed speaking to Resident #1 in an inappropriate manner and harsh tone of voice. The facility failed to ensure Resident #1 was treated with respect and dignity. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB135185,5MA215,RCF,11/8/2013,Resident #1 went without medication for about six days. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB145589,5MA215,RCF,1/5/2014,"Resident #2 slapped Resident #1 and Resident #3. Resident #2 had history of behaviors and striking other residents and staff. The facility failed to implement appropriate and effective interventions and monitoring to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB134075B,5MA215,RCF,8/12/2013,"The facility failed to adequately care plan related to falls and implement interventions for safety measures. Resident #1 suffered bruising. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB145843B,5MA215,RCF,12/22/2013,"The facility failed to provide a safe environment by not implementing interventions and staffing levels for residents who exhibit behaviors that resulted in an altercation between Resident #1 and Resident #2. Resident #1 was kicked in the foot by Resident #2, and both were frightened by the incident. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +NB145650A,5MA215,RCF,1/10/2014,"The facility failed to appropriately care plan with interventions and failed to utilize behavioral interventions regarding Resident #2's known behavioral issues. Resident #2 went into Resident #1's room, climbed into bed with him/her and touched Resident #1's genitalia which resulted in a physical altercation. The facilities failures to provide a safe environment is a violation of resident rights, is considered neglect of care resulting in sexual abuse and constitutes abuse.",3,2500,,,Sexual abuse +NB145650C,5MA215,RCF,1/10/2014,"The facility failed to appropriately care plan with interventions and failed to utilize behavioral interventions regarding Resident #2's known behavioral issues. Resident #2 went into Resident #1's room, climbed into bed with him/her and touched Resident #1's genitalia which resulted in a physical altercation. The facilities failures to provide a safe environment is a violation of resident rights, is considered neglect of care resulting in sexual abuse and constitutes abuse.",3,,,,Neglect +NB145650D,5MA215,RCF,1/10/2014,The facility failed to ensure a safe medication system was in place to ensure Resident #3's medications were properly managed and documentation was accurate. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +NB145650B,5MA215,RCF,1/10/2014,The facility failed to provide a safe medication administration system to ensure Resident #2 received his/her ordered medications. Resident #2 did not receive medications as prescribed to assist with behaviors. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +NB146704,5MA215,RCF,4/10/2014,"The facility failed to care plan appropriately and implement interventions regarding Resident #1's falls. He/she suffered skin tears, scratches and bruising. The facility failed to properly plan care regarding his/her needed assistance with toileting. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB147462,5MA215,RCF,6/17/2014,Resident #1 had a history of striking residents and was care planned to be removed from environmental stressors when upset with staff or other residents. Witness #1 walked away from Resident #1 as he/she yelled at him/her; Resident #1 followed Witness #1 into another residents' room and struck Resident #2 and Resident #3. Neither resident was harmed. Resident #1's care plan was not followed and is a violation of Oregon Administrative Rules.,2,,,, +NB147503,5MA215,RCF,6/16/2014,"The facility failed to assure timely medical treatment after Resident #1 fell, despite his/her complaints of pain, increased swelling and bruising, and inability to bear weight. Resident #1 was treated approximately seven (7) days after his/her fall on 6/16/14. Resident #1 was diagnosed with a fractured femur that required surgery. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NB147717,5MA215,RCF,7/13/2014,"Resident #1's service plan for staff stated to re-approach later if he/she became combative to allow time to calm down. Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) changed Resident #1's brief while Resident #1 screamed and hit them. RP2 held Resident #1's hands while changing his/her brief causing a bruise on Resident #1. He/she was fearful of RP2 and RP3. RP2 and RP3 failed to follow his/her care plan. RP2 used physical force, which constitutes physical abuse. The facility failed to ensure his/her care plan was followed and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +NB148862A,5MA215,RCF,10/9/2014,"On 10/9/14, Resident #1 slapped Resident #2 across the face twice. Resident #1 had a prior incident of hitting another resident; however the facility failed to appropriately care plan and implement interventions after the first incident. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB148862B,5MA215,RCF,10/9/2014,"Resident #1 had two prior incidents of hitting other residents. On 10/23/14, Resident #1 struck Witness 4 twice during his/her shower. Afterwards, Resident #1 went into the common area and slapped Resident #3 in the face. The facility failed to provide a safe environment and the failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NB149437,5MA215,RCF,12/2/2014,Resident #1 did not receive his/her medication and treatment as ordered. The facility failed to provide a safe medication administration system and the failure violates Oregon Administrative Rules.,2,,,, +NB148484,5MA215,RCF,9/11/2014,"Resident #1 and Resident #2 were not administered, one each, of his/her correct medications for approximately 13 days of August and September 2014. Neither resident experienced a negative outcome. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +NB149189,5MA215,RCF,11/7/2014,"The facility had made a safety plan for Resident #1 to be in line of sight of staff for safety supervision. Resident #1 was found down on the floor in another residents' room with an abrasion and had been there approximately an hour. The facility failed to ensure Resident #1 was safe and failed to have sufficient staffing to meet his/her safety needs. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB149637,5MA215,RCF,12/21/2014,"Resident #2 had history of sexual behavior towards staff and residents. On December 21, 2014, Resident #1 experienced a sexual assault including bruising to his/her upper thighs by actions of Resident #2. The facility failed to adequately care plan and failed to monitor and implement interventions to address Resident #2_x001A_s sexual behaviors. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse.",4,2500,,,Sexual abuse +CO15100,5MA215,RCF,5/21/2015,"On April 16, 2015, a condition was placed on the facility's license requiring a minimum of two (2) caregivers (excluding Med. Aides) in each neighborhood for day shift and evening shift, and a minimum of one (1) caregiver (excluding Med. Aides) in each neighborhood for night shift. + + + +A review of Baycrest Memory Care staffing reports, the following was substantiated: The facility failed to comply with caregiver staffing requirements. + + + +The facility's staffing reports beginning April 16, 2015 revealed the facility failed to follow the staffing requirements set out in Order Imposing License Condition #RCFCD15-007 (incorporated by reference). The facility's failure places residents at risk for abuse and/or neglect of care.",4,500,,, +NB150757A,5MA215,RCF,3/29/2015,"Resident #1 had a history of being combative with residents and his/her care plan states interventions for agitation before administering PRN medication. The facility failed to ensure Resident #1's care plan was followed and failed to continue to implement effective interventions regarding his/her behavior. Resident #1's behavior affected other residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,, +NB150962,5MA215,RCF,4/15/2015,"Resident #1 had multiple incidents of resident to resident physical and verbal contacts, and he/she was mainly the aggressor. The facility failed to care plan, document, and implement effective interventions to ensure resident safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151204,5MA215,RCF,5/4/2015,"Resident #1 was administered the incorrect fiber supplement, however he/she had no negative outcome. Multiple witnesses report difficulty in administering medications correctly and providing adequate care to residents due to lack of sufficient staffing. The facility failed to ensure sufficient staffing levels to ensure resident care needs are met and medications administered safely, exposing residents to potential harm. The failures are a violation of Oregon Administrative Rules.",2,,,, +CO15145,5MA215,RCF,7/16/2015,"On April 16, 2015, a condition (#RCFCD15-007) was placed on the facility_x001A_s license requiring a minimum of two (2) caregivers (excluding Med. Aides) in each neighborhood for day shift and evening shift, and a minimum of one (1) caregiver (excluding Med. Aides) in each neighborhood for night shift. + + + +On or about June 5, 2015, a notice of assessment of civil penalty (#RCFCP15-036) was served on you. The notice imposed a $500 penalty for each day after such notice was served that the License Condition is not met. Following receipt of the notice, Licensee did not timely request a contested case hearing but submitted payment of the civil penalty in full. A final order was issued and served on June 26, 2015. + + + +Upon a review of Baycrest Memory Care staffing reports from June 5, 2015 through June 30, 2015, the following was substantiated: The facility failed to comply with caregiver staffing requirements stated in the condition previously imposed. + + + +The facility_x001A_s staffing reports beginning June 5, 2015 through June 30, 2015 revealed the facility failed to follow the staffing requirements set out in Order Imposing License Condition #RCFCD15-007 on June 6, 12, 13, 14, 15, 23, 24, 25, 26, 27, 28, and 29, 2015. The facility_x001A_s failure placed residents at risk for abuse and/or neglect of care.",3,6000,,, +NB151009,5MA215,RCF,4/18/2015,"Resident #1 had known history of exposing and/or touching his/her genitals in the common area in view of other residents. On 4/18/15, staff found Resident #2's hands down Resident #1's pants in the common area. The facility failed to care plan appropriately and implement effective interventions regarding Resident #1's sexual behaviors, and failed to monitor to ensure resident safety in a safe environment. The facility's failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse.",2,,,,Sexual abuse +NB151254,5MA215,RCF,5/12/2015,"On 5/12/15, Resident #1 was not administered his/her ordered medication. He/she had no observable negative outcome. The facility failed to ensure medications were administered. The failure is a violation of Oregon Administrative Rules.",2,,,, +NB151286,5MA215,RCF,5/13/2015,"The facility failed to protect Resident #2 from Resident #1 and failed to try interventions or administer as needed medication. Resident #1 hit Resident #2 on the hand. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +NB152398,5MA215,RCF,8/7/2015,Resident #1's care plan and diet information did not match with regards to current diet orders. The facility failed to ensure his/her care plan and diet orders were accurate and updated. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +NB151874C,5MA215,RCF,7/11/2015,"Resident #1 was administered a bowel medication in error resulting in Resident #1 experiencing diarrhea unnecessarily that evening. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NB151874D,5MA215,RCF,7/11/2015,The facility failed to follow orders regarding Resident #1's bowel medication. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB151105A,5MA215,RCF,8/1/2014,"Resident #1's pain medication went missing and was not located in the facility. The facility failed to provide a safe medication system that prevents theft. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Financial abuse +NB151105B,5MA215,RCF,8/1/2014,"Resident #1 experienced pain; however he/she went without pain medication for approximately eight (8) days. The facility failed to ensure a safe medication administration system to ensure pain medication was available and administered to reduce pain. The failure resulted in Resident #1 experiencing unreasonable continued pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +NB151792,5MA215,RCF,6/13/2015,"Resident #1 had a history of hitting other residents. Resident #2 had a history of wandering into other residents' rooms. On 6/13/15, Resident #2 wandered into Resident #1's room and a physical altercation occurred. The facility failed to care plan and implement interventions to address behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151285B,5MA215,RCF,5/13/2015,"Resident #1 had a history of physically assaulting residents and staff. On 5/18/15, he/she became agitated and physically assaulted staff and residents, went to the hospital and returned the same day. The facility failed to update his/her care plan and implement interventions to address his/her behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151285C,5MA215,RCF,5/13/2015,"The facility failed to appropriately care plan and provide adequate service regarding Resident #1's food/fluid intake, indicated hunger, and weight tracking. Resident #1 had a weight decrease. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +NB151657A,5MA215,RCF,9/1/2014,"The facility failed to adequately care plan related to Resident #1's falls and failed to have adequate levels of staffing to meet his/her needs. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151657B,5MA215,RCF,9/1/2014,The facility failed to have updated documented and an accurate care plan related to Resident #'1s ulcer care and treatment. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +NB151084A,5MA215,RCF,4/25/2015,"On 4/25/15, Resident #1 grabbed Resident #2 causing injury and stated he/she would do it again. Staff was not aware this incident occurred and did not intervene. Resident #1 has hit Resident #2 in the past and targeted him/her. The facility failed to update or change Resident #1_x001A_s care plan to address his/her behaviors in an attempt to keep Resident #2 safe. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151084B,5MA215,RCF,4/25/2015,"On 5/3/15, Resident #1 scratched and hit Resident #2 while making inappropriate comments toward him/her, and Resident #1 stated he/she would do it again. Resident #1 has hit, scratched and yelled at Resident #2 in the past, and continued to target Resident #2. The facility failed to update or change care plans to attempt to protect Resident #2, resulting in Resident #2 being physically and verbally assaulted. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151084C,5MA215,RCF,4/25/2015,"Resident #1 made ongoing inappropriate verbal comments to residents in the neighborhood he/she lived in. He/she was prescribed medications to assist with behaviors but they were not always used and/or effective. Behavioral Support Services were sought but the facility did not follow the specialist recommendations. The residents of the neighborhood indicated fear and apprehension during an incident involving Resident #1 on 4/25/15. The facility failed to protect residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151084D,5MA215,RCF,4/25/2015,"On 10/9/14 and 11/13/14, Resident #1 had bruising on both wrists. Staff caused the bruising on 10/9/14 by holding Resident #1_x001A_s wrists against the shower chair. There was no incident report or other documentation in the facility regarding this incident and was not reported to APS. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151084E,5MA215,RCF,4/25/2015,"Resident #1 physically assaulted residents in the neighborhood he/she lived in. He/she was prescribed medications to assist with behaviors but they were not always used and/or effective. Behavioral Support Services were sought but the facility did not follow the specialist recommendations. The residents of the neighborhood indicated fear and apprehension during an incident involving Resident #1 on 4/25/15. The facility failed to protect residents from ongoing physical assaults. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB151306,5MA215,RCF,5/1/2015,"The facility failed to timely assess and timely seek medical attention as Resident #1_x001A_s condition continued to decline. Resident #1 was transported to the hospital for treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NB152436,5MA215,RCF,8/9/2015,"The facility failed to implement interventions and care plan appropriately regarding Resident #1's behaviors to keep Resident #2 safe. Resident #1 had a history of not liking Resident #2 and would be verbally and physically aggressive toward him/her. Incidents occurred on 8/9/15 and 8/21/15 with Resident #1 as the instigator. Following the 8/21/15 incident, Resident #1 was moved to another neighborhood. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB152472,5MA215,RCF,8/14/2015,"Reported Perpetrator 2 (RP2) used inappropriate verbal comments, such as profanity, while working in the neighborhood where Resident #1, Resident #2, and Resident #3 resided. RP2's actions are considered verbal abuse. The facility failed to ensure a safe environment for residents and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +NB152583B,5MA215,RCF,8/25/2015,"The facility failed to seek timely medical treatment regarding Resident #1's toenail issue and possible infection/injury, for approximately 25 days. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NB152968,5MA215,RCF,9/21/2015,"The facility failed to ensure care planned instructions of interventions were followed regarding Resident #1's combative behaviors. Resident altercations continued and was an unsafe environment. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +NB153074,5MA215,RCF,10/2/2015,Resident #1 had a non-injury fall on 10/2/15. Reported Perpetrator 2 (RP2) admitted to not turning on his/her tab alarm. The facility failed to ensure Resident #1's care plan was followed which violates Oregon Administrative Rules.,2,,,, +NB153388,5MA215,RCF,10/28/2015,"The facility failed to intervene and appropriately care plan with interventions to address Resident #1_x001A_s behaviors. Resident #1 was aggressive to other residents and staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +NB153389,5MA215,RCF,10/23/2015,The facility failed to properly plan care to address Resident #1's and Resident #2's behaviors to ensure safety. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +NB153197A,5MA215,RCF,10/18/2015,"The facility failed to care plan appropriately regarding Resident #2's behaviors that affected Resident #1 and staff. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NB153197B,5MA215,RCF,10/18/2015,"The facility failed to care plan appropriately regarding Resident #2's behaviors to ensure a safe and homelike environment. Resident #2's actions affected other residents and staff. The failure are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +NB153197C,5MA215,RCF,10/18/2015,The facility failed to care plan appropriately regarding Resident #2's exit seeking behaviors to ensure a safe environment. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +NB153720A,5MA215,RCF,11/27/2015,"Reported Perpetrator 2 (RP2) and Witness 2 engaged in a verbal dispute in front of residents, other staff and family. RP2 and Witness 2 did not treat others with dignity and respect. The facility failed to ensure staff were respectful to ensure a safe and homelike environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +NB153720B,5MA215,RCF,11/27/2015,"Resident #1 did not receive medications as prescribed and charted on the MAR. Resident #3 and Resident #4 did not receive PRN medications during the evening shift in a timely manner, resulting in unnecessary pain/discomfort. Reported Perpetrator 2 (RP2) failed to follow the interim care plan or behavior interventions for Resident #3. RP2 failed to administer PRN pain medication as requested to Resident #4. RP2's actions are considered neglect of care which constitute abuse. The facility failed to ensure a safe medication administration system and failed to ensure staff followed medication administration. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Neglect +NB164317,5MA215,RCF,1/18/2016,The facility failed to properly plan care and implement effective interventions regarding Resident #1's known behaviors and regarding Resident #2's and Resident #3's known history of wandering into others' rooms. Resident #2 and Resident #3 wandered into Resident #1's room while he/she was involved in a personal behavior. The failures are a violation of resident rights and is a violation of Oregon Administrative Rules.,2,,,, +NB154016B,5MA215,RCF,12/19/2015,Resident #1 went without a prescribed medication for three days. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.,2,,,, +NB154051A,5MA215,RCF,12/25/2015,Resident #1 was care planned to not have the recliner leg rests elevated when sitting in it. Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan. The facility failed to ensure Resident #1's care plan was followed. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +NB154051B,5MA215,RCF,12/25/2015,"Reported Perpetrator (RP2) was verbally abusive to Resident #4 and Resident #5, and RP2_x001A_s actions constitutes abuse. The facility failed to protect residents from verbal abuse to ensure a safe and homelike environment. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +NB154051C,5MA215,RCF,12/25/2015,Reported Perpetrator 2 (RP2) dispensed Resident #2's medications when he/she was lying flat and non-responsive; and did not ensure he/she swallowed the medications. RP2 was forceful in getting Resident #3 to take a shower and Resident #3 was heard refusing the shower stating it was too hot. RP2 failed to treat the residents with dignity and respect and failed to follow protocol. The facility failed to protect residents to ensure safe and homelike environment.,2,,,, +NB154051D,5MA215,RCF,12/25/2015,"The facility failed to provide a safe medication administration system. Reported Perpetrator 2 (RP2) failed to provide needed medication services, even after being retrained, to Resident #1, Resident #2 and Resident #6 which placed residents at risk of harm and harm. The facility failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +NB164780,5MA215,RCF,2/26/2016,The facility failed to ensure care plans were followed to ensure safety resulting in Resident #1 and Resident #2 slapping each other on the arm. Neither resident suffered injuries. The facility's failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +BH116719,5MA217,RCF,3/6/2011,The facility failed to ensure a safe environment resulting in the loss of Resident #1's wedding rings.,2,0,Not Substantiated,Substantiated,Financial abuse +CO13054,5MA217,RCF,4/26/2013,"A re-licensure survey completed on April 26, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to evaluate a change of condition, provide an RN assessment, develop interventions and monitor residents who experienced a change of condition. Resident #1 had ongoing injury falls without consistent monitoring or evaluation of interventions already in place. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH148459,5MA217,RCF,7/17/2014,RP2 was observed to be verbally inappropriate and rushed while providing care to Resident #1. RP2 did not respect the resident's wish. The facility failed to ensure Resident #1 was treated with respect and dignity. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD128962,5MA221,RCF,12/18/2011,"Resident #1 and Resident #2 were in a physical altercation with no injuries on December 18, 2011. Resident #1 was involved in another altercation five days earlier with another resident and was placed on alert monitoring for mood changes.",2,0,,, +RD129068,5MA221,RCF,12/30/2011,"Resident #1 pushed Resident #2 to the ground. Resident #2 was transported to the hospital and was diagnosed with a fractured shoulder. Resident #1 had prior incidents with no new interventions put in place. The facility failed to address Resident #1_x001A_s behaviors and care plan appropriately. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD120948,5MA221,RCF,8/14/2012,Resident #1 was agitated and angry. Staff continued to engage Resident #1 resulting in an escalation of his/her behavior. The facility failed to follow Resident #1_x001A_s service plan resulting in him/her sustaining a skin tear. The failure is a violation of Oregon Administrative Rules.,2,0,,,Physical Abuse +RD133375,5MA221,RCF,5/26/2013,"Resident #1 was left unattended while on the toilet as his/her caregiver left the room. During the absence of the caregiver, Resident #1 fell, resulting in a fractured hip. Resident #1's Care Plan stated he/she was at risk for falls, would often remove his/her tab alarm and attempted to get up unassisted. The only safety measures in place were to monitor and place the tab alarm in the middle of Resident #1's back. The facility failed to properly care plan for falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD133636,5MA221,RCF,6/23/2013,Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD135025,5MA221,RCF,9/10/2013,"Resident #1 was found on the floor on September 9, 2013. On September 12, 2013, Resident #1's physician evaluated his/her injury and wrote an order for x-rays. Resident #1 was not taken to the hospital for x-rays until September 17, 2013. Resident #1 sustained a dislocated and fractured shoulder. The facility failed to timely coordinate health services for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BO135454,5MA221,RCF,11/6/2013,Resident #1 had an unwitnessed fall in the hallway without injury. He/she was placed back into bed and his/her wheelchair was left at the bedside preventing Resident #1 from getting out of bed without assistance. The facility failed to assure his/her resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD135207,5MA221,RCF,8/14/2013,"Resident #1 was not monitored for side effects after starting new medication. Information regarding the new medication was not provided to ER/EMT staff, Resident #1's prescribing physician or authorized representative. Resident #1 was transported to the hospital twice for loss of cognitive and physical ability. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD146020,5MA221,RCF,2/3/2014,Resident #1 eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD146344,5MA221,RCF,3/8/2014,Resident #1 was involved in an altercation with Resident #2. No injuries were sustained. Resident #1 has a history of agitation. There have been no prior altercations between Resident #1 and Resident #2. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD146780,5MA221,RCF,3/25/2014,"Resident #1 hit Resident #2 in the forehead with a shoe when Resident #2 entered his/her room. Staff had been directed to monitor Resident #2's whereabouts due to recent altercations. The facility failed to provide a safe environment for Resident #1 and Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD146960C,5MA221,RCF,4/1/2014,"Resident #5 fell in the hallway. Over the next week his/her foot swelled, bruised and was tender to the touch. Resident #5's physician was not contacted until four days later and was not taken for x-rays until four days after the physician was notified. Resident #5 was diagnosed with an ankle fracture. The facility failed to timely coordinate health services for Resident #5. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD146824,5MA221,RCF,4/17/2014,Resident #1 eloped from the facility. He/she was redirected back into the facility without incident. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO147436,5MA221,RCF,5/1/2014,"The Reported Perpetrators were involved in an incident regarding redirecting Resident #1 from another resident's room. Resident #1 sustained a thumb size bruise above his/her wrist. The facility failed to protect Resident #1 from rough treatment due to not properly training staff regarding redirecting residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD147598,5MA221,RCF,5/15/2014,"Resident #1 complained of hip and leg pain beginning on 5/5/14. Resident #1 rarely complained of pain. Resident #1's physician evaluated him/her and ordered x-rays. Resident #1 continued to complain of pain even with ordered pain medication. X-rays were not taken until 5/15/14 when family took Resident #1 to the hospital. He/she was diagnosed with a broken femur. The facility failed to timely coordinate health services for Resident #1 who experienced prolonged pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD147652,5MA221,RCF,6/8/2014,"Resident #1 eloped from the facility by kicking out the vinyl slats in the courtyard gate. This is the second time Resident #1 has broken the courtyard gate and climbed through. He/she was redirected back into the facility without incident. No injuries were sustained. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",2,,,, +RD147657,5MA221,RCF,6/28/2014,"Resident #1 and Resident #2 were involved in an altercation. This was the second altercation within a week between Resident #1 and Resident #2. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD148458,5MA221,RCF,7/22/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. There have been multiple incidents between Resident #1 and Resident #2. The facility failed to implement adequate interventions regarding Resident #1 and Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD149674,5MA221,RCF,12/10/2014,Resident #1's care plan states he/she is a two-person transfer at all times. Reported Perpetrator 2 (RP2) attempted to assist him/her without the assistance of other staff. Resident #1 fell forward out of his/her wheelchair onto the floor. Resident #1 sustained skin tears on his/her right forearm. RP2 was found responsible for neglect which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +RD150711,5MA221,RCF,3/1/2015,"Resident #2 had Resident #1 on the floor with his/her hands around Resident #1's neck. The facility failed to implement adequate interventions to address Resident #2's behaviors. The facility also failed to provide an appropriate level of staff and train adequately. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +RD150919,5MA221,RCF,3/29/2015,"Resident #1 was a fall risk and fell out of bed the first two nights at the facility. Family came to visit the next day and took Resident #1 to the hospital where he/she was diagnosed with a hip fracture. A tab alarm was not being used although the facility did have an order from Resident #1_x001A_s physician. The facility failed to follow a physician_x001A_s order, train staff and appropriately care plan for Resident #1 regarding falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD151448A,5MA221,RCF,5/13/2015,"Resident #1 hit Resident #2 with his/her cane. Resident #2 sustained a bruise to his/her elbow. Both residents had a history of aggressive behaviors. The facility failed to implement interventions for Resident #1 and Resident #2's behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +CO15157,5MA221,RCF,8/11/2015,"The preliminary findings of the Residential Care Facility Re-licensure Survey which began August 3, 2015, and is currently in process, determined that the Facility is not in substantial compliance with the Oregon Administrative Rules for Residential Care Facilities and that the Facility's noncompliance places residents at harm and risk for harm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,,,,Neglect +RD152307,5MA221,RCF,7/15/2015,Resident #1 eloped from the facility. He/she was found in the front of the building. No injuries were sustained. The facility failed to assure that Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD152297A,5MA221,RCF,6/28/2015,"Resident #1 was able to complete his/her own activities of daily living prior to June 26, 2015. Over the course of ten days Resident #1 fell twice which resulted in him/her being transported to the hospital. There was no documentation for a change of condition or increased monitoring. The facility failed to assess, care plan and appropriately monitor after a significant change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD152297C,5MA221,RCF,6/28/2015,Resident #1's service plan stated nail care was to be done as needed after bathing. Resident #1's toenails were overgrown and rubbing raw areas on other toes. There was no facility documentation regarding the last time Resident #1's toe nails had been trimmed. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD152490,5MA221,RCF,8/5/2015,"Resident #1's service plan stated staff were to monitor and ensure he/she was ambulating with his/her walker. Resident #1 sustained a fall. The facility failed to service plan Resident #1 to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD152584,5MA221,RCF,8/1/2015,Resident #1 missed approximately seven patches in twelve days and anti-anxiety medication for approximately fourteen days. The medication was not delivered from the pharmacy and staff were not following up to find out why the medication was not delivered. The facility failed to administer Resident #1's medications according to physician's orders. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD152628,5MA221,RCF,5/21/2015,"Resident #1 was administered another resident's injection for blood sugar levels. Resident #1 was transported to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD153049,5MA221,RCF,9/29/2015,Resident #1 was administered another resident's medication in error. Resident #1 fell forward from a bench fifteen minutes later. Resident #1 was experiencing other health related problems that included low blood pressure and a lung infection. The fall cannot be attributed to the medication error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD153258,5MA221,RCF,10/20/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained scratches and gouges all over his/her face. Resident #1 had bruising on his/her chest. Both residents have been involved in altercations with other residents. The facility failed to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BO152069C,5MA221,RCF,7/11/2015,Resident #3 developed red marks on his/her bottom due to refusing brief changes and not being moved often enough. The facility failed to appropriately plan Resident #3's care. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD153818,5MA221,RCF,11/29/2015,Resident #1 and his/her bed were being changed by staff and Resident #1 fell off the bed. Resident #1 did not sustain injury. The facility failed to follow Resident #1's care plan resulting in him/her falling out of bed and assure that staff were properly trained. The failures is a violation of Oregon Administrative Rules.,2,,,, +RD154029,5MA221,RCF,12/17/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #1 and Resident #2 had been involved in previous altercations. Both residents sustained skin injuries. The facility failed to implement interventions to address resident behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BO164487,5MA221,RCF,12/7/2015,"Resident #1 and Resident #2 were involved in an altercation. Both residents had behaviors in the past. Resident #1 sustained a skin injury. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GB105687,5MA222,RCF,11/16/2010,"Resident #1 was prescribed a medication to take two times daily. The Medication Administration Record (MAR) showed to take one time daily, with a note below to take at 8am and 4pm. Despite the MAR error, Resident #1 received the appropriate dosage each day.",2,0,,, +GB117473A,5MA222,RCF,3/21/2011,"The Facility failed to provide a safe medication administration system to prevent theft or misuse of medications. Preponderance of evidence indicates Reported Perpetrator 2 stole and/or mismanaged the medications. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and financial exploitation and constitute abuse.",3,300,Substantiated,Substantiated,Financial abuse +GB117473B,5MA222,RCF,3/21/2011,"The Facility failed to provide a safe medication administration system to prevent theft or misuse of medications. The Medication Administration Records were inadequately maintained and theft of medications occurred. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and financial exploitation and constitute abuse.",3,0,,,Neglect +CO13036,5MA222,RCF,2/21/2013,"The facility failed to update Resident #3_x001A_s service plan; failed to re-evaluate and make appropriate changes to the service plan; and failed to re-assess when he/she experienced a significant change of condition. Resident #3 lost a significant amount of weight. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +GB134737,5MA222,RCF,10/16/2013,"The facility failed to provide a safe environment for Resident #1 and Resident #2 resulting in an altercation between the two and Resident #2 sustaining a skin tear. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GB145554,5MA222,RCF,12/24/2013,"The facility failed to provide a safe environment and failed to follow service plans for Resident #1 and Resident #2 resulting in an altercation between the two causing falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +GB146420,5MA222,RCF,3/19/2014,"Resident #1 did not have a guardian and was free to make his/her own choices. Resident #1 wanted to leave the facility to go to lunch with Witness #1 and Witness #2; however he/she was not allowed to leave the facility. The facility's failure is a violation of resident rights and is considered involuntary seclusion, by definition.",2,,,,Involuntary Seclusion +GB147615,5MA222,RCF,5/27/2014,The facility did not allow Resident #1 to go on outings with Witness #1 which is considered involuntary seclusion and constitutes abuse. The facility failed to ensure resident rights for Resident #1.,2,,,,Involuntary Seclusion +GB147482,5MA222,RCF,6/23/2014,Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) used physical force to pull Resident #1 from his/her room and pulled him/her down the hallway against his/her will. Resident #1 suffered bruising and a skin tear. The actions of RP2 and RP3 constitute physical abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +GB149644,5MA222,RCF,12/20/2014,"On 12/20/14, Resident #1 fell and was transported to the hospital and admitted for treatment. Prior to this date, he/she had had falls, which were not documented. Resident #1's physician ordered a tab alarm on 8/6/14; however Resident #1 didn't wear a tab alarm and staff weren't aware for him/her to wear one. The facility failed to update Resident #1's care plan to follow physician orders for a tab alarm, and failed to adequately care plan related to his/her falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +OR0001022800,5MA222,RCF,10/28/2015,,1,,Not Substantiated,Substantiated, +BC116421,5MA223,RCF,2/12/2011,The Facility failed to take reasonable precautions to prevent a resident from receiving bruising due to transfer techniques that were not appropriate for the resident. Staff transfers resulted in bruising to the resident which was evaluated at the hospital.,2,0,,,Neglect +BC120038,5MA223,RCF,5/11/2012,"Resident #1 declined in health and was admitted to hospice on May 2, 2012. On May 11, 2012 RP2 changed Resident #1's care plan to NPO (nothing by mouth; withhold food and fluids) without a physician's order. Resident #1 did not receive any liquids or food for almost 48 hours. The facility failed to ensure appropriate consultation prior to changing an order resulting in harm to Resident #1. The failure is a violation of Oregon Administrative Rules. RP2 was substantiated for neglect and constitues abuse.",3,0,Not Substantiated,Substantiated,Neglect +BC132313,5MA223,RCF,1/20/2013,"A nursing assessment was not completed for Resident #1_x001A_s change of condition. Resident #1 showed symptoms of decline starting in the early morning hours and was not transported to the hospital until the evening. The hospital determined that Resident #1 had suffered a stroke. Reported Perpetrator 2 (RP2) was found responsible for neglect of care which constitutes abuse. The facility failed to assess for a change of condition and obtain timely medical treatment for Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,Substantiated,Substantiated,Neglect +BC132926,5MA223,RCF,4/10/2013,"Resident #1 had $300.00 taken from his/her apartment by an unknown person. Witnesses stated this is the second time Resident #1 had money taken from their residence. There was no indication the facility put interventions in place following the first theft. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the money from Resident #1's apartment and is responsible for financial exploitation, which constitutes abuse.",3,300,Not Substantiated,Substantiated,Financial abuse +BC147564,5MA223,RCF,5/13/2014,"Resident #1 required total assist with toileting and care planned for two person assist with peri-care due to combative behavior. The facility failed to ensure timely assistance with toileting resulting in Resident #1 being left incontient. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC147631,5MA223,RCF,6/9/2014,"Resident #1 had severe hand contractures that required rolled up wash clothes in hands at all times to minimize injury and further contraction. Care plan directed staff to switch the washcloths twice daily. On the morning of June 9, 2014 Resident #1 was discovered without the washcloths in her/his hands and her/his left thumb was bent. An investigation was initiated, however staff were unable to provide information to explain the injury. The facility failed to ensure the care plan was followed and failed to provide a safe environment resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC147785,5MA223,RCF,6/24/2014,Complainant reported the facility was not providing adequate care regarding toileting assistance and teeth cleaning. Witness testimony and facility documentation revealed Resident #1's care needs were increasing and the facility was updating the care plan to address it. Staff were trained on the changes and the investigation concluded that Resident #1's teeth were not being adequately cleaned. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC149080,5MA223,RCF,10/13/2014,The facility failed to ensure a safe medication administration system resulting in two residents not receiving their medications for several days. The failure is a potential for harm and a violation of Oregon Administrative Rules.,2,,,, +BC149340,5MA223,RCF,11/16/2014,"Resident #1 had a physician's order for a medication patch to be on 12 hours and removed for 12 hours daily. On or about November 16, 2014, Resident #1 was observed with two pain patches. The facility failed to ensure medications were administered as ordered resulting in the potential for harm and is a violation of Oregon Administrative Rules.",2,,,, +BC149588,5MA223,RCF,11/30/2014,"Resident #1's ring was discovered missing. Law enforcement was notified and an internal investigation was unable to determine who took it. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for the theft, it is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BC150005,5MA223,RCF,12/17/2014,The facility did not timely follow up on Resident #1's medication refill order with the pharmacy resulting in the resident not receiving her/his medication for several days. The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC159895,5MA223,RCF,1/1/2015,RP2 gave Resident #1 an incorrect dosage of inhaler medication and indicated she/he had watched another staff give that amount previously. The facility failed to ensure medication was administered as ordered resulting in the potential for harm.,2,,,, +BC150111,5MA223,RCF,1/28/2015,Resident #1 did not receive her/his medication as ordered. Investigation revealed that the specific medication could not be located on the medication cart resulting in the resident not receiving the medication for two days. The medication was later found. The facility failed to ensure a safe medication administration system resulting in the potential for harm and is a violation or Oregon Administrative Rules.,2,300,,, +BC150256,5MA223,RCF,2/6/2015,Resident #1 was not administered her/his medications as ordered. Investigation revealed RP2 did not timely get the fax from the physician with the medication change. RP2 was counseled on withholding medications without a physician's order. The facility failed to ensure a safe medication administration system resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +BC159987,5MA223,RCF,12/26/2014,RP2 documented incorrectly administering the wrong dossage of medication to Resident #1 and Resident #2. The facility failed to ensure residents were administered medication as ordered resulting in the potential for harm. The failure is av violation of Oregon Administrative Rules.,2,,,, +BC150130,5MA223,RCF,1/9/2015,Resident #1 was given the wrong dosage of medication by multiple staff. Resident #1 did not suffer any negative outcome as a result of the errors. The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rule.,2,,,, +BC150475,5MA223,RCF,2/25/2015,Resident #1 received a prn anti-anxiety medication three times within a 24 hour period when the Medication Administration Record directed staff to provide it only once per day. The facility failed to ensure Resident #1's medication was administered as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC150451,5MA223,RCF,1/7/2015,"The facility failed to ensure an accurate Medication Administration Record resulting in Resident #1 not receiving her/his medication as ordered between January 7 and February 27, 2015. Investigative findings revealed Resident #1 did not experienced any negative outcome as a result of the error. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC150662,5MA223,RCF,3/14/2015,"Resident #1 was administered the wrong dose of narcotic medication by RP3. RP3 was new to the position and made the medication error when RP2 left RP3 unsupervised. The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150639,5MA223,RCF,3/19/2015,"Resident #1 was administered another resident's medication resulting in sedation. The facility failed to ensure medications were administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,,Neglect +BC150637,5MA223,RCF,3/5/2015,"Resident #1's medication was misfiled resulting in two missed doses. There was no negative outcome as a result of the error and the failure is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150559,5MA223,RCF,3/11/2015,"The facility failed to administer medication as ordered resulting in Resident #1 receiving another resident's medication. RP2 was distracted when passing out medications. Resident #1 was monitored with no observable negative outcome. The failure is violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150925,5MA223,RCF,4/8/2015,"RP2 initialed that Resident #1 received her/his scheduled medication and was called away on another task before she/he could administer it. Upon return, RP2 forgot to administer the medication. There was no known negative outcome as a result. The facility failed to ensure medication was administered as ordered and is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150923,5MA223,RCF,4/2/2015,"Resident #1 did not received a scheduled dose of narcotic medication. No negative outcome was observed as a result of the medication error. The facility failed to ensure medications were administered as ordered resulting in the potential of harm and is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150924,5MA223,RCF,4/6/2015,"Resident #1 and Resident #2 each missed a scheduled dose of medication by RP2. There was no observable negative outcome as a result of the medication. The facility failed to ensure medications were administered as ordered and is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150813,5MA223,RCF,3/15/2015,"The facility failed to ensure medications were administered as ordered resulting in multiple medication errors and the potential for harm. The failure is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150823,5MA223,RCF,4/1/2015,"Resident #1 had an order to be given a medication every four hours. RP2 did not administer the medication on two ocassions due to the fact the medication was not refrigerated and she/he was unable to get ahold of the facility RN for direction. There was no negative outcome as a result. The facility failed to ensure Resident #1 received her/his medication as ordered and is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC150973,5MA223,RCF,4/7/2015,"The facility failed to ensure medication was administered timely after a new prescription arrived at the facility. There was no observable negative outcome as a result and is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC151054,5MA223,RCF,4/11/2015,"Resident #1 did not receive her/his medications as ordered on one known ocassion, resulting in the potential for harm. There was no negative outcome as a result of the error and is a violation of Oregon Administrative Rules. Due to an increased number of medication errors, corrective action was initiated on or about April 15, 2015 which included the submission of a plan of action and reporting requirements.",2,,,, +BC152784,5MA223,RCF,8/29/2015,The facility failed to ensure Resident #1's care plan was followed resulting in a non-injury fall and is a violation of Oregon Rules.,2,,,, +BC153199,5MA223,RCF,10/10/2015,"The facility failed to ensure Resident #1's care plan was followed resulting in being left soaked in urine and vomit for several hours. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC153908,5MA223,RCF,12/8/2015,"On December 8, 2015 at 5:20 pm RV1 pulled RV2's wheelchair causing him/her to fall backwards onto the ground. While RV2 was on the floor, RV1 rammed his/her walker into RV2's chest. RV2 sustained two bumps and a laceration to his/her face. RV1 has a history of being protective of his/her room and has had multiple physical altercations with other roomates. The facility's failure to provide a safe and secure environment is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB116035,5MA233,RCF,12/24/2010,"Resident #1 and Resident #2 had a history of striking others, and Resident #1 believed Resident #2 was his/her spouse and followed him/her around. Resident #1 had behavioral interventions in place, however were not followed resulting in an altercation between Resident #1 and Resident #2 on 12/24/10.",0,0,,, +RB116392,5MA233,RCF,1/21/2011,The facility failed to assess the interventions in place were affective to maintain a safe environment for Resident #1 and Resident #2.,2,0,,, +RB116936,5MA233,RCF,5/5/2011,"During shift change, Resident #1 was administered his/her roommates medication rather than his/her own. The error was caught immediately and reported to all necessary parties. Resident #1 was monitored, provided additional fluids and was on alert charting every two hours concluding no negative outcome from this error. Protocol for medication administration was changed to not conflict with shift changes.",2,0,,, +RB116977,5MA233,RCF,5/9/2011,"Resident #1 hit at Reported Perpetrator 2 (RP2) and Witness 2 while they attempted to take off his/her undergarment, and RP2 squeezed his/her hand but denied squeezing hard. There was no documentation regarding Resident #1's behaviors or interventions in his/her service plan to provide clear direction to staff when he/she exhibited behaviors.",2,0,,, +RB118118,5MA233,RCF,9/25/2011,Resident #1 and Resident #2 were roommates. Resident #2 does not like others in his/her space or belongings. Resident #1 had a history of wandering into others_x001A_ rooms and taking/moving personal items. There were two incidents on 9/25/11 where Resident #2_x001A_s behavior escalated due to Resident #1_x001A_s behaviors resulting in an altercation.,2,0,,, +RB128887,5MA233,RCF,1/7/2012,Resident #2 was care planned to redirect from other residents and staff to closely monitor him/her with other residents. The facility failed to follow Resident #2's care plan resulting in a resident to resident altercation with Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB120455,5MA233,RCF,6/19/2012,The facility failed to provide a safe environment resulting in a resident to resident altercation between Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB120447A,5MA233,RCF,6/24/2012,Resident #1 was administered another residents medication exposing him/her to harm. The facility failed to administer medications as ordered. The failure is a violation of Oregon Administrative Rules.,1,0,,,Neglect +RB120447B,5MA233,RCF,6/24/2012,"Resident #1 was administered another residents medication. Following this error, his/her prescribed medication was ""held"" without physician's orders exposing him/her to harm. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RB120447C,5MA233,RCF,6/24/2012,Resident #1 was administered another residents medication on 6/24/12; however his/her physician was not notified timely. The facility failed to assure timely medical treatment. The failure is a violaton of Oregon Administrative Rules.,2,0,,, +RB120727,5MA233,RCF,7/27/2012,"Resident #1 required daily intervention to understand basic needs, he/she needed redirection and he/she was care planned as a known fall risk from sitting on tables and dressers. On 7/27/12, he/she fell from a table in his/her room that collapsed. On 7/28/12, he/she sat on a table which broke and he/she fell hurting his/her bottom. The facility failed to follow his/her care plan and failed to properly plan with interventions. The failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",2,0,,,Neglect +RB120565,5MA233,RCF,7/16/2012,The facility failed to provide a safe environment and failed to follow the care plan for Resident #1 resulting in a resident-to-resident altercation. The failures are a violation of Oregon Administrative Rules.,2,0,,, +RB121362,5MA233,RCF,10/12/2012,"Resident #1 was not provided appropriate care in his/her activities of daily living as care planned, resulting in poor hygiene, unclean bedding, soiled clothing; and his/her call bell was not within reach. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +CO13001,5MA233,RCF,12/5/2012,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services evidenced by the re-licensure survey completed on December 5, 2012 and preliminary findings from Adult and Protective Service (APS) reports.",3,0,,,Neglect +RB121778,5MA233,RCF,11/24/2012,"The facility failed to have a safe medication administration documentation system, resulting in the uncertainty of Resident #1 being administered a double dose of medication or not. He/she was monitored and there were no signs of adverse affects; however this failure exposed Resident #1 to potential harm. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RB121761,5MA233,RCF,11/27/2012,"Resident #1 was dependent from staff to manage all phases of bladder care, he/she required on-going intervention to understand basic health and safety needs, and he/she was unable to make independent decisions. On 11/27/12, he/she was observed wandering with visibly wet clothing and was not assisted timely, resulting in unreasonable comfort. The facility failed to provide service to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB121931,5MA233,RCF,12/18/2012,"Resident #1's medication was discovered on the floor in his/her room at approximately 9:00-9:30am, it was identified as his/hers and was administered to him/her; however documentation indicated it had been administered at 6:00am. The medication had been on the floor and handled by two people prior to medication being administered to Resident #1. The facility failed to ensure a safe medication administration system and failed to take reasonable precautions related to infection control, exposing Resident #1 to potential harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,, +RB121879,5MA233,RCF,12/12/2012,"Resident #1 was administered an antiviral eye medication without a physician order, that caused him/her pain. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,,Neglect +RB121949,5MA233,RCF,12/20/2012,"Witness 3 stated he/she was possibly interrupted by residents when administering medications. The medication cart was located in the common area against the wall in front of the office and residents walk back and forth in front of the medication cart. The facility failed to provide a safe medication administration system and failed to store medications in a secured environment. The failure is a violation of Oregon Administrative Rules. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB121962B,5MA233,RCF,12/18/2012,"The facility failed to provide a safe environment; failed to implement interventions; and failed to train staff to use methods of transferring as noted in Resident #3's care plan. Resident #3 was uncooperative with care and had a history of sliding off bed to the floor and refused to call for help. On 12/19/12, Resident #3 slid off the bed to the floor, refused assistance and appeared alright; however the staff person wasn't able to operate the lift. Resident #3 was made comfortable on the floor and went to sleep. He/she was alright being on the floor. The failures are a violation of resident rights and are a violation of Oregon Administrative Rules. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB121962C,5MA233,RCF,12/18/2012,"Resident #4's narcotic pain reliever was initialed as administered on 12/18/12. A narcotic pill was discovered on the floor in Resident #5's room, it was not his/hers, but thought to be Resident #4's. Witness 4 handed Witness 3 a pill that was found on the floor of a residents apartment; however the pill did not belong to any residents. The facility failed to provide a safe environment causing potential harm and the failure is a violation of Oregon Administrative Rules. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB132056,5MA233,RCF,1/2/2013,"Resident #1 was care planned requiring on-going and daily intervention by staff to understand the basic health and safety needs. He/she was care planned with a tab alarm and mattress on the floor by bed to reduce the risk of injury from nightmares and history of rolling or trying to get out of bed. Resident #1 was discovered on the floor with a skin tear and had removed his/her tab alarm. The facility failed to implement on-going and daily/nightly measures to assist him/her with basic safety needs. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB121953,5MA233,RCF,12/16/2012,"The facility failed to intervene when Resident #1's condition changed of rolling out of bed. He/she experienced facial injuries and bruising. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,,Neglect +RB132052,5MA233,RCF,1/7/2013,"Resident #1 was care planned for known history of behaviors. Resident #1's behavior increased and he/she kicked Resident #2 in the thigh area. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,, +RB121958A,5MA233,RCF,12/21/2012,"Resident #1 fell over backwards in his/her wheelchair in the common area and sustained two skin tears. He/she had a history of falls from his/her wheelchair; was not supposed to be left in his/her wheelchair; and was only to be in wheelchair for meals and transportation only from room to room. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,,Neglect +RB121958B,5MA233,RCF,12/21/2012,"Resident #1 was left with a gait belt on and was discovered later that he/she had taken the gait belt off and wrapped it around his/her neck stating he/she wanted to end his/her life. The gait belt was removed before he/she was able to tighten it. Resident #1 had stated that he/she wanted to end his/her life before. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB132185,5MA233,RCF,1/15/2013,"Resident #1 was care planned and known to strike out at other residents entering his/her room and staff were to redirect him/her and help remove other residents from room. Resident #2 was care planned and known to wander and wander into other residents' rooms. On 1/15/13, Resident #2 wandered into Resident #1's room, and Resident #1 slapped Resident #2 in the face, yelled at him/her to get out and shoved him/her. The facility failed to follow care plans and monitor Resident #1 and Resident #2 resulting in an altercation. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,,Neglect +RB132324,5MA233,RCF,2/1/2013,"Resident #1 and Resident #2 were care planned and had known behaviors. On 2/1/13, they were involved in an altercation where Resident #1 grabbed Resident #2's arm and twisted hard. The facility failed to monitor and provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,,Neglect +RB132077,5MA233,RCF,1/7/2013,"Resident #1 was care planned as total assist in transfers; needing tab alarm in place; and was known to remove the tab alarm. Resident #1 was in bathroom without assistance at unknown time during the night and fell, getting arm stuck between the wall and grab bar, and complained of arm pain. He/she was checked three times during the night and had tab alarm off each time. The facility failed to follow the care plan and failed to implement other measures regarding the removal of tab alarms. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,,Neglect +RB132191A,5MA233,RCF,1/15/2013,"Resident #1 and Resident #2 were care planned to receive medications according to physician orders; the right medications, the right dose and at the right time. Per documentation, Resident #1 was not administered his/her medications as ordered. He/she was to be watched for symptoms of pain, grimacing, moaning related to pain. On 1/10/13, he/she was observed pulling his/her hair and grinding his/her forehead on the table. Resident #2's treatment of barrier cream was missed. The facility failed to administer medication and treatments as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,,Neglect +RB121951,5MA233,RCF,12/20/2012,"Resident #1 was care planned for full hands on assist with grooming and hygiene. His/her toenails were observed to be long and curving over the end of the toes; toenails were thick and yellow in color; and his/her left toenail had fallen off. The facility failed to assist with grooming and the failure is a violation of Oregon Administrative Rules. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB121973,5MA233,RCF,12/23/2012,"Resident #1 was care planned as a one person assist, and may also use a Hoyer lift. Resident #1 was left on the floor and made comfortable from approximately 4:00 a.m. until 6:30 a.m. when another staff person came on shift to assist. There was one staff person on shift at time of incident and staff member did not know how to use the Hoyer lift. Per witness statements, he/she was at least a two person transfer even with a Hoyer lift. The facility failed to provide a safe environment; failed to adequately assess and properly plan care; failed to train staff; and failed to have adequate staffing levels. The failures are a violation of Oregon Administrative Rules. + + + +This incident was used in part to issue a license condition that went into effect January 4, 2013.",2,0,,, +RB132683,5MA233,RCF,3/9/2013,"Resident #1 walked out of the facility using an unsecured/unlocked door. The facility was undergoing a remodel and the carpet workers were made aware that the door leading to the outside of the facility needed to be locked and secured at all times. However, at the time of investigation, the door was unsecured / unlocked and the garage door to the outside of the facility was also open. Local law enforcement located Resident #1 and was transported back to the facility. The facility failed to provide a safe environment and failed to take reasonable precautions. The failures are a violation of Oregon Administrative Rules. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,, +RB132768,5MA233,RCF,3/15/2013,"The facility failed to have a service plan available to staff that provided clear direction regarding Resident #1's mobility plan. Documentation indicated many inconsistencies. Resident #1 was walking with his/her walker and tripped over a step from the living room to the dining room and fell to the ground. There were no visible injuries. The failure is a violation of Oregon Administrative Rules. + + + +This incident occurred after a license condition went into effect January 4, 2013.",2,0,,, +RB133434,5MA233,RCF,6/6/2013,Resident #1 and Resident #2 had prior known behaviors with other residents. The facility failed to provide a safe environment resulting in an altercation of pushing and shoving between Resident #1 and Resident #2. The failures are a violation of Oregon Administrative Rules.,2,,,, +RB133344,5MA233,RCF,5/28/2013,"Resident #1 had a history of agitation towards staff and other residents and care planned for staff to ""try to"" keep him/her in view at all times. Resident #1 hit Resident #2 in the jaw. The facility failed to provide a safe environment by not following Resident #1's care plan. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +RB135405,5MA233,RCF,12/7/2013,"Resident #1 was care planned for staff to check on him/her frequently; however staff were unclear how often ""frequently"" meant. Resident #1 eloped from the building for an undetermined amount of time, was found and returned to the facility. He/she was cold and hungry. The facility failed to ensure Resident #1's care plan gave clear direction and failed to ensure staff were properly trained resulting in Resident #1 experiencing unreasonable discomfort. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,, +RB135428,5MA233,RCF,12/15/2013,"The facility failed to implement interventions and monitoring after a resident to resident incident occurred earlier in the day between Resident #1 and Resident #2. Later in the day, Resident #1 was still upset with Resident #2 and kicked him/her and pulled Resident #2's hair. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +CO14048,5MA233,RCF,2/28/2014,,,,,, +RB148520,5MA233,RCF,9/7/2014,"Resident #1 experienced a significant change of condition from independent ambulation to needing a wheelchair, and assistance with transfers. Resident #1 fell and suffered a fractured bone after getting out of his/her wheelchair and attempting to ambulate on his/her own. The facility failed to assess, intervene, implement interventions, and appropriately care plan regarding Resident #1_x001A_s change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RB148617A,5MA233,RCF,9/12/2014,"The facility failed to ensure appropriate bathing to Residents, exposing them to potential for harm. The failure is a violation of Oregon Administration Rules.",2,,,, +RB148617D,5MA233,RCF,9/12/2014,"The facility failed to obtain a treatment order for Resident #5's catheter care, and failed to provide catheter care. Resident #5 suffered an infection. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +RB148617B,5MA233,RCF,9/12/2014,The facility failed to ensure Resident #1's dietary supplement was available to administer as physician ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB148051B,5MA233,RCF,8/4/2014,"The facility failed to provide a safe medication administration system to ensure Resident #1 received his/her narcotic pain medication as ordered. Resident #1 experienced unreasonable pain. The failure is a violation of resident rights, is considered neglect of pain and constitutes abuse.",2,,,,Neglect +RS150252A,5MA233,RCF,2/11/2015,"Resident #1 was to have frequent night time checks and also to have 2 hour checks for a medical reason. On 2/11/15, Resident #1 fell out of bed in the night and remained on the floor for an unknown amount of time. Reported Perpetrator 2 (RP2) failed to perform the night time checks for Resident #1. He/she sustained a bruise to his/her face; however two days later stated complaints of pain, went to the hospital and was treated for a small internal head injury. RP2's failure is considered neglect of care resulting in unreasonable discomfort and head injury, which constitutes abuse. The facility failed to ensure Resident #1's care plan was followed and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +RS150252B,5MA233,RCF,2/11/2015,Reported Perpetrator 2 (RP2) documented that he/she performed night time checks on Resident #1 as care planned; however RP2 did not actually conduct the checks. RP2 falsified records. The facility is responsible for the overall conduct of staff.,2,,,, +RS154047,5MA233,RCF,11/25/2015,"The facility failed to ensure physician orders were followed for residents with orders that allow alcohol, and failed to ensure residents without orders were not given alcohol. Reported Perpetrator 2 (RP2) gave wine to 5 residents, and only 2 had orders allowing beer. The failure is a violation of resident rights and violates Oregon Administrative Rules.",2,,,, +RD116125A,5MA238,RCF,12/13/2010,"On 12/13/10, Resident #1 was not administered his/her newly prescribed evening medication. The error was discovered the following morning.",2,0,,, +RD116125B,5MA238,RCF,12/13/2010,Staff did not follow Resident #1's care plan or behavior plan when his/her behaviors escalated.,2,0,,, +RD116370,5MA238,RCF,1/16/2011,Reported Perpetrator 2 (RP2) did not treat Resident #1 with dignity and respect when he/she spoke to Resident #1 and failed to follow the care plan related to his/her emotional interventions.,2,0,,, +RD116846,5MA238,RCF,3/27/2011,"Resident #1 eloped from the facility in cold weather from approximately 3pm - 4:20pm, and was returned by law enforcement; however staff were unaware that he/she was out of the building. The electromagnetic on the front door was discovered to be malfunctioning and the door would open if pulled hard or blown open by high winds. Resident #1 was cold but unharmed and stated he/she went for a walk.",2,0,,, +RD120045,5MA238,RCF,3/18/2012,The sounding of Resident #1's tab alarm was not timely addressed resulting in him/her slipping out of his/her wheelchair. No injuries were noted. The facility failed to follow Resident #1's care plan which is a violation of Oregon Administrative Rules.,2,0,,, +RD135371,5MA238,RCF,12/9/2013,"Resident #1 was care planned for verbal behaviors with interventions for staff to follow. Reported Perpetrator 2 (RP2) cussed at and called Resident #1 names, failing to follow the interventions. RP2's actions are considered verbal abuse. The facility failed to ensure respect and dignity and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Verbal/Mental abuse +CO14049,5MA238,RCF,2/27/2014,,,,,, +RD149407,5MA238,RCF,11/27/2014,The facility failed to ensure Resident #1 was safe and within a safe environment when Reported Perpetrator 2 (RP2) expressed desire to have Resident #1 redirected away from him/her. RP2's attempts to keep Resident #1 away resulted in Resident #1 falling but without injury. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +RD149677,5MA238,RCF,12/11/2014,"On 12/11/14, Reported Perpetrator 2 (RP2) documented giving Resident #1 a narcotic pain tablet at 7am, 8am, and 10am; however video surveillance shows him/her asleep in the living room. One tablet of this narcotic pain normally caused Resident #1 to be extremely lethargic, but he/she was awake after 9am. RP2 is found responsible for theft of Resident #1's narcotic medication and is considered financial exploitation. The facility failed to provide a safe medication administration system and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +OR0001008900,5MA238,RCF,9/28/2015,,0,,,Substantiated, +CO11032,5MA240,RCF,1/6/2011,"The facility failed to appropriately evaluate, monitor interventions for their effectiveness, and timely complete a documented RN assessment after Resident #3 experienced a significant weight loss. Resident #3 experienced a severe (42 pound) weight loss within a 6 month period. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RB105970,5MA240,RCF,12/19/2010,RP3 has been witnessed to be rude and negative towards residents and family members. The facility failed to assure residents' rights resulting in loss of dignity. RP3 is no longer employed at the facility.,2,0,,, +RB116404,5MA240,RCF,2/22/2011,A resident of the Facility was able to exit the Facility through an alarmed door. Staff was aware the door had been opened and discovered the resident outside and redirected the resident back inside the Facility. The resident was not harmed as a result of leaving the locked unit at the Facility.,1,0,,, +RB117184,5MA240,RCF,6/7/2011,The facility failed to follow Resident #1's care plan resulting in minor harm. The failure is a violation of resident rights is considered neglect of care and constitutes abuse.,2,0,,,Neglect +RB129193,5MA240,RCF,2/4/2012,"Resident #2 was observed with his/her hand down Resident #1_x001A_s pants in a common area. Both Resident #1 and Resident #2_x001A_s care plans note sexually inappropriate behaviors. The facility failed to follow the care plans for Resident #1 and Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB129022,5MA240,RCF,1/23/2012,"Resident #1 and Resident #2 were found in Resident #2_x001A_s room, on the bed fully clothed. Resident #2 had a history of sexual aggressiveness with staff. The facility failed to give provide instruction on redirecting residents exhibiting behaviors. The failure is a violation Oregon Administrative Rules.",2,0,,, +RB129518,5MA240,RCF,3/15/2012,Resident #2 did not like other residents in his/her room and also had a history of being physically aggressive. Resident #1 had a history of wandering into other resident_x001A_s rooms. Resident #1 wandered into Resident #2_x001A_s room resulting in a resident to resident altercation. The facility failed to follow the care plans of both residents. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB129969,5MA240,RCF,5/1/2012,"Resident #1 grabbed Resident #2_x001A_s chest area with a full hand. Resident #1 has a history of being sexually inappropriate with staff and other residents. The facility failed to follow care plan and monitor Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB129139,5MA240,RCF,2/3/2012,Resident #2 does not like other residents in his/her room. Resident #1 has a history of wandering into other resident_x001A_s rooms. Resident #1 wandered into Resident #2_x001A_s room resulting in a resident to resident altercation. The facility failed to follow the care plans of both residents. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB132019,5MA240,RCF,12/29/2012,"Reported Perpetrator 2 (RP2) made inappropriate statements regarding Resident #1 in his/her presence. RP2 admitted to making the statements but said it was made under his/her breath, and not loud enough for anyone to hear. RP2 was found responsible for verbal abuse. The facility failed to protect Resident #1 from verbal abuse. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +RB132274,5MA240,RCF,1/26/2013,"Resident #1 was a fall risk and had several falls during a short period of time, with no amendments to his/her care plan. On January 28, 2013, Resident #1 was sent to the hospital due to a hip fracture. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB132454,5MA240,RCF,2/15/2013,Reported Perpetrator 2 (RP2) was overheard scolding Resident #1 for spitting his/her food. RP2 pushed Resident #1_x001A_s food out of his/her reach. Resident #1 was upset and crying. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +RB133078B,5MA240,RCF,4/27/2013,Resident #1 had a history of aggression toward other residents and staff. He/she was involved in another resident to resident altercation due to wandering into another resident_x001A_s room. The facility failed to follow his/her care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB133078A,5MA240,RCF,4/27/2013,Resident #2 said that Resident #1 hit him/her. Staff did not witness the incident. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB133079,5MA240,RCF,4/26/2013,"Resident #1 and Resident #2 were involved in an altercation. Per the residents care plans, they both have behaviors. The facility failed to address Resident #1 and Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.",2,,,, +RB133795,5MA240,RCF,12/30/2012,"Resident #1 sustained a fractured hip due to a fall in his/her room. APS did not receive a self-report from the facility for Resident #1's injury fall or any previous falls. The facility failed to adequately update Resident #1's service plan to address fall interventions and report falls to APS. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +RB133882,5MA240,RCF,7/19/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #1 sustained a skin tear on his/her right arm. Resident #2 did not sustain injury. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB134357,5MA240,RCF,9/4/2013,Resident #1 was care planned for a pressure alarm in his/her recliner. The alarm malfunctioned and did not alert staff when Resident #1 got up. Resident #1 was found on the floor and had sustained skin injuries. The facility received a new alarm and it was functioning properly when the investigator was visiting. The assigned staff member did not respond to the alarm as care planned while the investigator was there. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB135335,5MA240,RCF,12/4/2013,Reported Perpetrator 2 (RP2) was witnesses responding to Resident #1's request to go to bed using inappropriate verbal comments. RP2 was found responsible for verbal abuse. RP2 had training documented and signed by RP2 regarding verbal and mental abuse of residents. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RB145631,5MA240,RCF,1/7/2014,Resident #2 hit Resident #1 in the stomach. Resident # has a history of yelling at other residents and resident altercation. The facility failed to address residents' behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +RB146618,5MA240,RCF,4/5/2014,"Resident #1 had a history of falls. Resident #1 was found on the floor and had sustained injury. Resident #1's service plan stated that staff would provide standby assistance with transfers. The facility failed to follow Resident #1's service plan regarding transfers. The facility also failed to update Resident #1's service plan to address fall interventions. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RB146864,5MA240,RCF,4/20/2014,Resident #1 was found on the floor by the television and had sustained skin injuries. He/she has a history of falls. Resident #1's care plan states to use wheelchair for transportation only. Resident #1 was sitting in his/her wheelchair in the common area. The facility failed to follow Resident #1's service plan regarding the use of a wheelchair. The failure is a violation of Oregon Administrative Rules.,1,,,, +RB147437,5MA240,RCF,6/17/2014,"This Letter of Determination amends the previously issued Notification of Findings. Resident #1's Care Plan stated he/she needed total assistance in the shower. The plan stated Resident #1 got dizzy in the shower and needed a shower chair to sit on. RP2 stated he/she had Resident #1 stand at the handrail in the back of the shower when RP2 turned away and Resident #1 fell to the ground, sustaining a head injury as well as shoulder and heel pain. RP2 failed to follow Resident #1's care plan, which is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +RB148964,5MA240,RCF,10/13/2014,"Resident #1 activated his/her call light for assistance. Resident #1 did not receive a response for fifteen to twenty minutes. Resident #1 fell sustaining a laceration across his/her right hand. He/she was transported to the hospital. The facility failed to timely respond to Resident #1's call for assistance. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB148785,5MA240,RCF,10/1/2014,"Resident #1's care plan stated that he/she had become weaker in the last month and was not able to ambulate and transfer by him/herself. Resident #1 was found on the floor of his/her room. He/she sustained skin tears to his/her elbows. The facility failed to adequately update Resident #1's care plan to address fall interventions. The facility also failed to assess Resident #1 for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +RB149055,5MA240,RCF,10/18/2014,Resident #1 was care planned to have a mattress on the floor next to his/her bed when he/she is in bed. Resident #1 was found on the floor of his/her room. Resident #1 sustained bruising to his/her left elbow. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +RS151229,5MA240,RCF,3/31/2015,"It was reported that the facility failed to protect residents from inappropriate comments. Upon investigation, it was determined that Reported Perpetrator 2 (RP2) did use a tone that could be interpreted as loud and rude in the manner she/he speaks to others. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +RS152335A,5MA240,RCF,8/1/2015,Reported Perpetrator 2 (RP2) was witnessed arguing with Resident #1 due to him/her exhibiting behaviors. Inappropriate verbal comments were made by RP2 toward Resident #1. The facility failed to care plan for Resident #1's behaviors and assure his/her resident rights. The failures are a violation of Oregon Administrative Rules.,2,,,, +RS152335B,5MA240,RCF,8/1/2015,Reported Perpetrator 2 (RP2) was witnessed slapping Resident #1 on the back of the head with a pair of gloves. RP2 was found responsible for physical abuse. The facility failed to care plan for Resident #1's behaviors and provide a safe environment. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +RS152650,5MA240,RCF,8/28/2015,Resident #1 and Resident #2 were involved in an altercation due to Resident #1 being in Resident #2's room. No injuries were sustained. The facility failed to follow the care plan for Resident #2 regarding keeping other residents out of his/her room. The failure is a violation of Oregon Administrative Rules.,2,,,, +RS152770,5MA240,RCF,7/12/2015,Reported Perpetrator #2 (RP2) threw a blanket at Resident #1 and called him/her a brat and a baby. RP2 is responsible for emotional abuse. The facility failed to ensure Resident #1 was treated with dignity and respect. This was a failure of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RS152621,5MA240,RCF,8/20/2015,"Resident #2 was found in Resident #1's room with his/her hand down Resident #1's pants. Resident #2 had a history of sexually inappropriate behaviors. The facility failed to care plan appropriately and implement interventions regarding Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse.",2,,,,Sexual abuse +RS152577,5MA240,RCF,8/17/2015,"Reported Perpetrator 2 (RP2) was witnessed physically and verbally abusing Resident #1, Resident #2 and Resident #3. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment and properly train staff regarding abuse reporting. The failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Physical Abuse +RS152670B,5MA240,RCF,8/31/2015,"Resident #1 entered Resident #3's room and started going through Resident #1's belongings. A physical altercation ensued. The facility failed to implement interventions to address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS152670C,5MA240,RCF,8/31/2015,"Resident #1 was involved in an altercation with Resident #4. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS152812,5MA240,RCF,9/12/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 had a history of aggressive behaviors. Resident #1 sustained red marks on his/her neck and face. The facility failed to implement appropriate interventions to address Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS152977A,5MA240,RCF,9/26/2015,Resident #1 and Resident #2 are cognitively impaired. A witness heard Reported Perpetrator 2 (RP2) use profanity toward Resident #2. A witness also heard RP2 speaking to Resident #1 in a derogatory manner. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RS152977B,5MA240,RCF,9/26/2015,"Reported Perpetrator 2 (RP2) was witnessed being rough and impatient with Resident #1, Resident #2 and Resident #3. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +RS153116,5MA240,RCF,10/11/2015,"Resident #1 and Resident #2 were involved in an altercation. Resident #2 had a history of aggression. Resident #1 was knocked to the ground. Resident #1 sustained abrasions as a result. The facility failed to implement interventions to address Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS153633,5MA240,RCF,11/17/2015,"Resident #1 entered Resident #2's room and was found choking Resident #2. Resident #1 had a history of agitation and aggression. The facility failed to implement appropriate interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +RS153996,5MA240,RCF,12/19/2015,"Resident #1 had a history of behaviors in the past. Resident #1 hit Resident #2 in the nose causing skin injury. The facility failed to implement interventions to address Resident #1_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS164300,5MA240,RCF,1/14/2016,"Resident #1's service plan states that staff are to place a geo mat on the floor beside his/her bed. Resident #1 was found on the floor next to his/her bed. He/she did not sustain injury. The geo mat was under the bed, as staff did not replace it after providing care. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +RS164335,5MA240,RCF,10/1/2015,Resident #1 lost weight and was care planned to have nutritional supplemental shakes provided. For two days staff forgot to provide the shakes to Resident #1. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD116377,5MA241,RCF,1/20/2011,Reported Perpetrator 2 failed to follow interventions in the care plan when Resident #1 became argumentative and RP2 yelled and argued with Resident #1.,2,0,,, +RD116720,5MA241,RCF,3/13/2011,Staff failed to follow the care plan to redirect residents when behaviors escalated and RV2 slapped RV1 on the head.,2,0,,, +RD117385,5MA241,RCF,5/22/2011,"Resident #1 was new to the facility, frequently attempted to exit the building and the care plan identified interventions. He/she attempted to exit the front office window, was re-directed, and soon after exited the backyard door. The motion sensor was malfunctioned and did not alert staff. Resident #1 was found across the street and returned unharmed.",2,0,,, +RD117683,5MA241,RCF,8/1/2011,Resident #1's care plan was not followed for staff to brush and clean his/her teeth and dentures twice a day; and for his/her hair shampooed and styled once a week.,2,0,,, +RD118491B,5MA241,RCF,11/12/2011,The facility failed to provide a walker to Resident #1 according to the hospital discharge instructions. He/she fell without injury shortly after he/she arrived at the facility.,2,0,,, +RD120877,5MA241,RCF,7/22/2012,"Approximately one hour after Resident #1 was administered his/her own medication; he/she was administered another residents_x001A_ medication by Reported Perpetrator 2 (RP2) while engaged in other required tasks. Resident #1's physician was contacted, was noted to be ""sluggish"" all day and staff monitored for 24 hours. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,0,,, +RD121996,5MA241,RCF,12/26/2012,"Resident #1 eloped without staff knowing. Local law enforcement found Resident #1 approximately eight blocks away from the facility. He/she was gone for an hour or less, and was wearing appropriate clothing for the weather. The facility's garage door was unlocked and door alarm temporarily disable due to carpet installers in the building. The facility failed to provide a safe environment resulting in Resident #1 eloping, which exposed him/her to harm. The failures are a violation of Oregon Administrative Rules.",2,0,,, +RD133805,5MA241,RCF,7/3/2013,Residents #1 and #2 left the facility when Resident #2 keyed in the code to get out of the front door. The residents were returned without injury. Resident #2 was care planned for being an elopement risk but had never left through the front door before. Witnesses stated Residents #1 and #2 talked all day about leaving the facility on the date of the elopement; staff did not address the issue. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO14044,5MA241,RCF,1/22/2014,"The facility failed to monitor Resident #3 and Resident #4 who required pain control and evaluation. Resident #3 and Resident #4 experienced uncontrolled pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +RD145573,5MA241,RCF,12/21/2013,"Resident #1 had a diagnosis of long and short term memory loss, brain injury and emotional/mental trauma. As evidenced by witness statements, Reported Perpetrator 2 (RP2) engaged in sexual behavior with Resident #1. The facility failed to provide a safe environment. The failure is a violation of resident rights. Reported Perpetrator 2 is found responsible for sexual abuse.",2,,Not Substantiated,Substantiated,Sexual abuse +RD146637,5MA241,RCF,3/16/2014,"Resident #1 successfully eloped from his/her room and was found approximately a mile away and returned to the facility unharmed. Prior to moving in, Resident #1 was known to regularly walk from town to town and back. Since living at the facility, he/she spent most of his/her time in his/her room. The facility failed to care plan appropriately and ensure his/her safety in his/her room. The failures are a violation of resident rights and Oregon Administrative Rules.",2,,,, +RD153000,5MA241,RCF,9/24/2015,"The facility failed to follow Resident #1's care plan and monitor resulting in an altercation with Resident #2. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB133926,5MA242,RCF,7/26/2013,"Reported Perpetrator 2 (RP2) got into an altercation with Resident #1, when the resident did not want cares provided. The incident resulted in bruises and a skin tear to Resident #1's hand. An eyewitness stated RP2 grabbed Resident #1's hand and swung his/her hand toward the bed. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +ES105484,5MA243,RCF,10/13/2010,"Facility staff failed to follow Resident #1's care plan which called for assisting the resident into bed at night so that his/her legs could be elevated to prevent skin breakdown. The resident routinely refused to sleep in his/her bed, however staff did not contact the resident's physician or explore any other alternatives related to having the resident's legs elevated to prevent breakdown. As a result, the resident experienced skin breakdown.",2,0,,,Neglect +ES117185B,5MA243,RCF,6/15/2010,"The facility failed to ensure nail care services for Resident #1 resulting in long, unkempt toenails. The failure is a violation of OARs.",2,0,,, +ES118589,5MA243,RCF,11/26/2011,"Reported Perpetrator 2 tried to redirect Resident #1 multiple times, became impatient, and cussed within hearing of Resident #1.",2,0,,, +ES128956,5MA243,RCF,1/16/2012,RP2 attempted multiple times to keep Resident #1 in his/her room due to him/her having a contagious illness. RP2 became frustrated because Resident #1 would not stay in his/her room and cussed at Resident #1. This was heard by a witness. RP2 is found responsible for verbal abuse. The facility failed to protect Resident #1 from inappropriate verbal conduct. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +ES118306,5MA243,RCF,10/22/2011,The facility had remodeling done to the outside courtyard and residents were allowed back into the newly remodeled area. Resident #1 fell twice within a 24 hour period in about the same place in the courtyard sustaining injuries. The concrete sloped and there was a two inch gap between the sidewalk and the adjoining landscape dirt that was filled with soft bark mulch. The facility failed to provide a safe physical environment for residents. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES133736,5MA243,RCF,7/9/2013,A preponderance of the evidence presented in the report reveals that Reported Perpetrator 2 (RP2) yelled obscenities at Resident #1 and shoved a wash cloth in Resident #1's mouth while Resident #1 was yelling. The facility failed to protect Resident #1 from rough treatment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +ES149025,5MA243,RCF,10/19/2014,"Complainant reported RP2 was observed slapping and yelling at Resident #1 during care. Witness testimony and facility documentation revealed RP2 had previous incidents regarding RP2's verbal and physical behavior towards residents since December 2013. The facility failed to ensure a safe environment. The failure is a violation of resident rights, is considered neglect of care resulting in verbal and physical abuse. RP2 was found responsible for verbal and physical abuse.",2,,Substantiated,Substantiated,Neglect +ES146248,5MA243,RCF,3/2/2014,"Resident #1 experienced increased aggressive behavior resulting in minor harm to Resident #2 and Resident #3. The facility failed to adequately care plan to address the aggressive behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES146385,5MA243,RCF,3/14/2014,"RP2 alerted staff when she/he noticed that Resident #1's liquid narcotic was tampered with. Drug testing was conducted and RP2's test came back positive when a second test was done. RP2 was suspected of the theft, however could not be verified. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES150185,5MA243,RCF,2/9/2015,"Resident #1 pushed Resident #2 causing a bump to her/his head. The facility failed to adequately care plan and monitor Resident #1's ongoing aggressive behavior resulting in Resident #2 being sent to the hospital for an evaluation. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ES152695,5MA243,RCF,9/3/2015,"Resident #1 was identified as a fall risk. The facility failed to adequately care plan for falls after the removal of a devise that prevented falls resulting in continued falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES164202,5MA243,RCF,12/6/2015,"RV1's service plan dated November 3, 2015 stated that his/her bed was to be in the lowest position and a fall mat at the bedside when RV1 was in bed. On or about November 6, 2015 RV1 fell from his/her bed and sustained bruising and pain as a result. RV1's fall mat had been moved and was not in place at the time of the fall. Witness #1 stated that a few days after the RV1's fall, the fall mat was observed against the wall and again not next to RV1's bed. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES164402,5MA243,RCF,1/22/2016,"RV1 was a resident of the facility and had a history of agitation and verbal aggression. Facility documentation indicates that on January 21, 2016 RV1 was agitated and had a verbal outburst of aggression. On or about January 22, 2016 RV1 was observed hitting other facility residents and staff with a newspaper. The facility's failure to provide a safe and secure environment is a violation of the Oregon Administrative Rules (OAR's).",2,,,, +ES164519,5MA243,RCF,2/1/2016,"A complaint regarding a resident to resident altercation was received on or about February 1, 2016. Facility documentation indicates that between December 7, 2015 and February 9, 2016, RV1 was involved in six incidents of resident to resident altercations. RV1 was involved in three resident to resident altercations between December 19 and December 26, 2015 but no updates were comleted to his/her service plan until January 14, 2016. The facility failed to provide a safe and secure environment.",2,,,, +ES164666,5MA243,RCF,2/16/2016,"RV1's service plan stated that he/she could be physically aggressive with staff and other residents and that facility staff was to offer snacks, walks or talks to distract him/her. On or about February 16, 2016 RV1 was agitated and following staff. RV1 rammed RV2 with his/her assistive device. The facility's failure to provide a safe environment is a violation of the Oregon Administrative Rules.",2,,,, +OR0001054205,5MA243,RCF,1/22/2016,,0,,Not Substantiated,Substantiated, +OR0001054208,5MA243,RCF,1/22/2016,,0,,Not Substantiated,Substantiated, +HB116575B,5MA245,RCF,3/22/2011,"A Facility staff member failed to follow the care plan for Resident #1 with respect to using a gait belt for every transfer. The staff member used a technique he/she witnessed somebody else doing, instead of how the care plan indicated the resident's transfers should be performed.",1,0,,, +HB116668,5MA245,RCF,4/4/2011,RP2 administered Resident #1 another resident's medication. Resident #1 was observed without negative outcome. RP2 was removed from medication administration. The facility failed to ensure Resident #1 was administered medication as prescribed resulting in the resident receiving the wrong medication. The failure is a violation of OARs.,2,0,,, +HB146869,5MA245,RCF,4/23/2014,RP2 and RP3 sprayed water into Resident #1's mouth to stop her/him from screaming. RP2 and RP3 were found responsible for physical abuse. The facility failed to ensure Resident #1 was treated with respect and dignity and provide a safe environment. The failures are violations of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +HB148066,5MA245,RCF,8/8/2014,"Resident #1 resided in a secure facility and was identified as at risk for elopement. On or about August 8, 2014, Resident #1 eloped from an unlocked gate in the courtyard and was discovered seven (7) hours later on a public bus, 17 miles from the facility. The facility failed to ensure a safe and secure environment that created a risk of serious harm, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB148382,5MA245,RCF,9/3/2013,"Resident #2 experienced increased aggressive behavior resulting in altercations with Resident #1 and Resident #3. The facility failed to adequately monitor and care plan to address Resident #2's behaviors. The failures are violations of resident rights, are considered nelgect of care and constitute abuse.",2,,,,Neglect +HB150443,5MA245,RCF,2/25/2015,"The facility failed to ensure a safe medication administration system resulting in the theft of multiple residents' unused narcotic medications. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for theft of narcotics, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +MS116867,5MA246,RCF,4/23/2011,"A correct medication count was completed at the beginning of the night shift on 4/22/11. The medication count the next morning at 7am, 4/23/11 discovered narcotic medication pills were missing as well as a hard copy narcotic medication prescription. Reported Perpetrator 2 (RP2) was in charge of the key for the narcotic and non-narcotic medication drawers during the night shift. Preponderance of evidence indicates RP2 had involvement in the missing narcotic medications and the prescription.",2,0,Not Substantiated,Substantiated,Financial abuse +MS129431,5MA246,RCF,3/7/2012,"Resident #1 had a medical condition that caused his/her toe nails to grow irregular. The facility failed to provide assistance with nail care for Resident #1's foot, until it was brought to their attention by Witness 2. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS133183,5MA246,RCF,4/7/2013,Reported Perpetrator 2 (RP2) was witnessed being verbally inappropriate with Resident #1 and Resident #2. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MS145587,5MA246,RCF,1/3/2014,"The facility kept Resident #1 and Resident #2's personal incidental funds (PIF) in a locked desk drawer. An unknown individual took money out of the desk, and this person is responsible for theft, which is considered financial exploitation and constitutes abuse. The facility failed to adequately protect Resident #1 and Resident #2's money from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS150362,5MA246,RCF,2/24/2015,Resident #1 had history of elopement prior to move-in and had exit seeking behaviors after moving into the facility. Resident #1 attempted to leave the facility on 2/12/15 and eloped from the facility on 2/24/15. The facility failed to address or implement interventions in Resident #1's care plan regarding elopement risk to keep him/her safe. The failure is a violation of Oregon Administrative Rules and exposed Resident #1 to harm.,2,,,, +BH116670,5MA249,RCF,9/12/2010,Resident #1 had no prior history of exit seeking behavior; however he/she eloped from the courtyard gate that was left unsecured after landscaping work was performed. He/she was located and returned to the facility unharmed.,12,0,,, +BH129057B,5MA249,RCF,1/20/2012,RP2 was observed restraining Resident #1 in her/his wheelchair and then again in a recliner to prevent her/him from ambulating. The facility failed to protect Resident #1 from corporal punishment. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for wrongful use of physical restraint and substantiated for abuse.,2,0,Not Substantiated,Substantiated,Restraints +BH129057C,5MA249,RCF,1/20/2012,Witness #3 failed to notify appropriate staff after witnessing RP2 roughly handle and physically restrain Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH147611,5MA249,RCF,6/19/2014,RP2 was observed being verbally inappropriate to Resident #1 and readily apologized afterwards. The facility failed to ensure Resident #1 was treated with respect and dignity and is a violation of Oregon Administrative Rules.,2,,,, +BH153514,5MA249,RCF,3/13/2015,"The facility failed to adequately monitor Resident #1 as care planned resulting in a resident to resident altercation. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,,,,Neglect +CO11005,5MA252,RCF,1/11/2011,,0,0,,, +BC146865,5MA252,RCF,3/8/2014,Resident #1 was a fall risk and was service planned to have a motion alarm next to his/her bed to alert staff when he/she was trying to get out of bed. The alarm had not been turned on. Resident #1 fell sustaining rug burns on his/her legs. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC146877,5MA252,RCF,4/20/2014,Resident #1 often yells when caregivers approach him/her. A Witness statement indicated that Reported Perpetrator 2 (RP2) got close to Resident #1's ear and screamed. The facility failed to assure Resident #1's rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO15021,5MA252,RCF,12/18/2014,"A re-licensure survey completed on December 18, 2014, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to monitor Resident #3 consistent with their evaluated needs and service plans related to falls. Resident #3 experienced harm due to an injury fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC152980,5MA252,RCF,9/25/2015,Resident #1 eloped from the facility during a happy hour event. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC153287,5MA252,RCF,10/22/2015,"Staff reported that Reported Perpetrator 2 (RP2) gave Resident #1 his/her breakfast plate in an abrupt manner. Also, that RP2 made a demeaning comment to Resident #1. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +RB116429,5MA254,RCF,2/7/2011,"Resident #2 had a history of aggressive behaviors and was known to not only go in other residents rooms, but specifically Resident #1's room as it was in the same location and orientation as the resident's friend on another hall. Resident #2 was found to have gotten physical with Resident #1 when Resident #1 asked Resident #2 to leave his/her room, causing bruising to Resident #1's wrists.",2,0,,,Neglect +RB118346,5MA254,RCF,10/28/2011,RP2 documented that she/he administered medication to Resident #1 when there was no medication available. Facility failed to order Resident #1's medication timely resulting in the resident not receiving two doses of her/his medication. There was no harm as a result of the medication error. The failure is a violation of OARs.,2,0,,, +RB118453,5MA254,RCF,11/11/2011,RP2 covered Resident #1's mouth to keep her/him from yelling and was verbally inappropriate after the resident urinated. The facility failed to assure resident rights.,2,0,,, +RB129196,5MA254,RCF,2/4/2012,Resident #1 was prescribed scheduled narcotic medication twice a day for pain. Documentation revealed that RP2 failed to administer Resident #'1 narcotic medication at noon. Resident #1 did not report any increased pain as a result of the error. The facility failed to ensure Resident #1's medication was administerd as ordered resulting in a missed dose. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB129562,5MA254,RCF,3/17/2012,"Resident #1 has a history of altercations with other residents and staff are directed to monitor her/his location. Resident #1 has been refusing medications that help stabilize her/his mood. Resident #1 was observed disturbing Resident #2 who woke up and pushed Resident #1 down. On a separate occasion Resident #1 was observed in the dining room and hit Resident #3. Later that day, Resident #1 was in an altercation with Resident #4. The facility failed to appropriately monitor Resident #1 resulting in altercations. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB129391A,5MA254,RCF,2/29/2012,Resident #1 was observed pushing Resident #2. Resident #1 has a history of aggressive behavior and care planned with interventions when Resident #1 is agitated. Resident #2 has a history of yelling out which agitates other residents. The facility failed to follow the care plan resulting resident to resident altercation. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB129391C,5MA254,RCF,2/29/2012,"Resident #4 nudged Resident #1 because she/he was in Resident #4's seat. Resident #1 responded by slapping Resident #4. Resident #1 has a history of aggressive behavior and is care planned with interventions to address it. The facility failed to provide a safe environment resulting in negative behavior escalating, affecting another resident. The failure is a violation Oregon Administrative Rules.",2,0,,, +RB129940,5MA254,RCF,4/24/2012,"On or about April 22, 2012, Resident #1 was sent to the hospital and admitted in serious condition due to stage 2-3 pressure ulcer and dehydration. Witness testimony revealed facility staff observed a skin breakdown the day before but failed to document or notify appropriate staff. The facility failed to evaluate, refer to the facility nurse and document interventions when Resident #1 experienced a significant change of condition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB120534,5MA254,RCF,6/28/2012,Resident #1 had a scheduled narcotic pain medication. RP2 failed to administer Resident #1's pain medication on one occasion. There was no negative outcome as a result of the medication error. The facility failed to ensure medications were administered as ordered. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB121347,5MA254,RCF,10/16/2012,Resident #1 was given Resident #2_x001A_s morning medications. Resident #1 was monitored and had no negative effects from the medications. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administration Rules.,2,0,,, +RB121569,5MA254,RCF,11/6/2012,Staff observed Resident #1 being pushed down by Resident #2. No injuries or harm was observed. Resident #1 had a known history of aggressive behavior towards other residents and care planned for consistent monitoring and redirection. The facility failed to follow Resident #1's service plan resulting in an altercation. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB121690,5MA254,RCF,11/22/2012,"Resident #2 has a history of aggressive behavior and care planned to redirect from other resident's rooms. On or about November 22, 2012, Resident #2 entered Resident #1's room and engaged in a physical altercation resulting in injury to both residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB132812,5MA254,RCF,3/30/2013,Law Enforcement contacted the facility regarding Resident #1. He/she had eloped from the facility. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB134356,5MA254,RCF,9/5/2013,"Reported Perpetrator 2 (RP2) was witnessed slapping Resident #1's hand away after Resident #1 grabbed RP2's buttocks. Resident #1 indicated there was some pain; no injuries were sustained. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for slapping Resident #1, which constitutes physical abuse.",2,,,,Physical Abuse +RB134981,5MA254,RCF,11/4/2013,"The facility failed to continue to monitor and update Resident #1's service plan despite his/her continued aggressive behavior towards other residents. This failure is considered neglect of care, constitutes abuse, and violates Oregon Administrative Rules.",2,,,,Neglect +RB135409,5MA254,RCF,12/10/2013,"Resident #1 was care planned to be directed away from Resident #2 if they are within the same room. While facility staff were in another room out of line of sight, Resident #1 approached Resident #2 and an altercation ensued. Resident #1 received a laceration from this altercation. The facility failed to monitor Resident #1 and Resident #2 as specified in Resident #1's service plan. This failure is considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +RB145670,5MA254,RCF,1/7/2014,"Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan resulting in Resident #1 sustaining a fall with injury. This failure is considered neglect of care, and constitutes abuse. The facility failed to ensure Resident #1's care plan was followed which is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +RB149241,5MA254,RCF,11/7/2014,The facility allegedly failed to follow Resident #1's care plan resulting in a fall. An investigation determined no facility wrondoing was identified.,,,,, +RB149539,5MA254,RCF,12/7/2014,"The facility failed to assess and intervene in relation to Resident #1_x001A_s falls. Resident #1 had repeated falls and the facility did not adequately update his/her service plan. Resident #1 sustained another un-witnessed fall with an injury to his/her head requiring hospital care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RS153510,5MA254,RCF,11/8/2015,"The facility failed to adequately care plan for Resident #1_x001A_s frequent falls. Resident #1_x001A_s care plan was not clear on how many times Resident #1 was to be provided bathroom checks. Resident #1 suffered a fractured pelvis after falling while attempting to go to the bathroom without assistance. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +OR0001022400,5MA254,RCF,10/28/2015,,1,,Not Substantiated,Substantiated, +OR0001022401,5MA254,RCF,10/28/2015,,1,,Not Substantiated,Substantiated, +GP105648,5MA255,RCF,11/10/2010,A bubble pack of medications that should have been in a locked drawer was is an unsecured place on the medication cart.,2,0,,, +GP116998,5MA255,RCF,5/17/2011,Staff failed to report on Resident #1's change of condition when he/she began hoarding food in his/her mouth creating a risk for potential harm.,2,0,,, +GP117274,5MA255,RCF,6/9/2011,Resident #1's money and property was discovered missing. These items were taken by an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +GP129246,5MA255,RCF,2/15/2012,Resident #1's pain controlling medication was removed from the medication card in late 2011 and was discovered by facility staff in mid-February 2012. Reported Perpetrator 2 is responsible for the theft of medications. The facility failed to provide a safe medication administration system that prevents theft. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +GP133413,5MA255,RCF,6/4/2013,"Facility staff were seating Resident #1 in a recliner with the foot rest raised blocked by an end table in the up position to keep him/her from scooting to the front of the chair. There was no doctor_x001A_s restraint order in place for Resident #1. The facility failed to assess the need of a restraint for Resident #1 and failed to have a doctor_x001A_s order. The failure is a violation of resident rights, is considered a wrongful use of a physical restraint of an adult and constitutes abuse.",2,,,,Restraints +GP133421A,5MA255,RCF,6/4/2013,Reported Perpetrator 2 yelled at Resident #1 and Resident #2. The facility failed to insure Reported Perpetrator 2 treated residents with dignity and respect. This failure is a violation of Oregon Administrative Rules.,2,,,, +GP133419A,5MA255,RCF,6/4/2013,Reported Perpatrator 2 (RP2) yelled innapropriately at Resident #1 while performing care duties. The facility failed to protect Resident #1 from yelling and innapropriate comments. This failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +GP133419B,5MA255,RCF,6/4/2013,"Reported Perpetrator 2 (RP2) handled Resident #1 roughly while performing care duties. The next day Resident #1 had a bruised face. RP2 was found responsible for rough handling of Resident #1, which constitutes physical abuse. The facility failed to protect Resident #1 from rough treatment. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +GP147124,5MA255,RCF,5/7/2014,"Resident #1 had a history of exit seeking and on 5/6/14 he/she had exhibited signs of agitation, aggression, and exit seeking. He/she was directed to go to his/her room, without care planned interventions offered. Resident #1 opened the window and fell out suffering a fracture to his/her back and was unable to walk after this incident. The window alarm did not sound. The facility failed to follow his/her care plan and failed to take reasonable precautions to ensure window alarms were functioning. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,450,,,Neglect +GP151485A,5MA255,RCF,6/5/2015,"Reported Perpetrator 2 (RP2) was physically and emotionally abusive to Resident #1. The facility failed to ensure residents were being treated with dignity and respect; were free from abuse; and failed to ensure staff reported abuse or suspected abuse. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,350,Substantiated,Substantiated,Physical Abuse +GP151485B,5MA255,RCF,6/5/2015,"Reported Perpetrator 2 (RP2) was neglectful in care to Resident #2. RP2's actions constitute abuse. The facility failed to ensure residents were being treated with dignity and respect; were free from abuse; and failed to ensure staff reported abuse or suspected abuse. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Neglect +GP151485C,5MA255,RCF,6/5/2015,"Reported Perpetrator 2 (RP2) was physically abusive to Resident #3. The facility failed to ensure residents were being treated with dignity and respect; were free from abuse; and failed to ensure staff reported abuse or suspected abuse. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Physical Abuse +MM105960,5MA259,RCF,11/8/2010,"The facility failed to follow Resident #1's care plan resulting in the resident not receiving a mechanical soft diet on one occasion and failed to ensure wheelchair breaks were locked resulting in at least two falls with minor skin injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM105918,5MA259,RCF,12/10/2010,"The facility failed to provide a safe environment resulting in the loss of multiple residents' clothing items. The clothing items were returned, however it is unable to be determined if Witness #1 or Witness #2 were responsible for the thefts.",2,0,Not Substantiated,Substantiated,Financial abuse +MM117552,5MA259,RCF,7/19/2011,RP2 administered Resident #1's injectable antibiotic medication twice in the same day to make up for a missed dose the previous day. RP2 failed to document the incident or notify the physician. There were no observable negative effects from the incident and RP2's employment was terminated. The facility failed to ensure physician orders were followed resulting in the potential for harm.,2,0,,, +MM118380,5MA259,RCF,10/29/2011,Resident #1 required sit-to-stand transfer machine. Resident #1 reported RP2 did not use the sit-to-stand transfer machine. Resident #1 slipped out of bed and found with neck caught in the bed rail causing bruising. The facility failed to ensure Resident #1's Service Plan was being followed.,2,0,,, +MM120002,5MA259,RCF,5/4/2012,"Resident #1 had a history of skin tears due to fragile skin and required two person transfer using hoyer lift. On May 4, 2012, staff observed Resident #1's arm behind her/him while in the hoyer lift and moved it resulting in a skin tear. The facility failed to ensure proper use of hoyer lift resulting in skin tear. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM120509,5MA259,RCF,6/27/2012,"Resident #1 was identified as an elopement risk and had a history of wandering. The facility failed to have an operational door alarm resulting in the successful elopement of Resident #1 through the unsecured courtyard. Resident #1 was located by police and returned to the facility several hours later cold, wet and tired. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +MM133195,5MA259,RCF,5/9/2013,It was reported Residents #1 and #2 had an altercation. Resident #1 was reported to have 5 incidents of physical aggression in the past 6 months. The facility failed to properly care plan for Resident #1's behaviors and the failure is a violation of Oregon Administrative Rules.,2,0,,, +MM120729,5MA259,RCF,7/25/2012,It was reported Resident #1 had orders for two types of the same medication. Reported Perpetrator 2 (RP2) stated he/she did not look at the name on the bottle of the medicine and administered the wrong one to Resident #1. Resident #1 was transported to the hospital for potential side effects and risk of harm. RP2 failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +MM148441,5MA259,RCF,8/29/2014,"Resident #1 was observed to choke Resident #2 with her/his own collar. Witness testimony and facility documentation revealed Resident #1 had recently been diagnosed with a UTI and both residents were exhibiting agitated behaviors. The facility failed to appropriately monitor behaviors resulting in a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,,,,Neglect +MM150447,5MA259,RCF,3/3/2015,"The facility failed to adequately monitor and care plan for Resident #1resulting in negative behavior affecting others. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM152588,5MA259,RCF,8/19/2015,The facility failed to follow residents' care plan resulting in an altercation and is a violation of Oregon Administrative Rules.,2,,,, +MM164371,5MA259,RCF,1/18/2016,"RV1 and RV2 had a history of altercations with one another. Witness #2 and Witness #3 indicated that RV1 was a food seeker and it has caused conflicts with other facility residents. On or about January 18, 2016, RV1 and RV2 were involved in an altercation over food. The facility's failure to address food as a possible trigger in RV1's care plan is a violation of the Oregon Administrative Rules.",2,,,, +HB116556B,5MA261,RCF,3/10/2011,"The facility failed to appropriately monitor Resident #1's lower leg extremity as requested by the physician and addressed on her/his March 4, 2011 service plan. The service plan updated on March 10, 2011 failed to address Resident #1's lower leg extremity. The facility failed to document Resident #1's condition or ensure monitoring was being conducted resulting in worsening of the leg that required transportation to the hospital for treatment. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB128842,5MA261,RCF,1/4/2012,RP2 was observed cussing at and about Resident #1 causing the resident to be frightened. RP2 was held responsible for verbal abuse. The facility failed to protect Resident #1 from verbal abuse. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HB129801,5MA261,RCF,4/13/2012,RP2 failed to lock the shower chair resulting in Resident #1 falling to the floor. Resident #1 was transported to the hospital and diagnosed with a fractured hip. The facility failed to provide a safe environment resulting in moderate harm to Resident #1. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect and constitutes abuse.,3,0,Not Substantiated,Substantiated,Neglect +HB134067,5MA261,RCF,8/6/2013,"Resident #1 and #2 had an altercation as the result of Resident #1 finding Resident #2 going through Resident #1's closet. Resident #2 fell, had a bump on his/her head and was transported to the hospital for evaluation. No serious injuries were reported. Due to a prior incident, Resident #2's Interim Service Plan at the time of the incident stated the closets were to be locked. The facility failed to provide a safe environment. The failure is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB135079,5MA261,RCF,11/15/2013,Resident #1 and Resident #2 have been observed to be sexually intimate in Resident #2's room. Both Resident #1 and Resident #2 have histories of sexually inappropriate behavior with each other. Resident #1's care plan failed to provide staff direction on how to respond to this behavior. Resident #2 was on 30 minute checks and later issued a move out. The facility failed to appropriately care plan resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB152074,5MA261,RCF,1/3/2015,"The facility failed to assess and intervene when Resident #1 experienced falls. Resident #1 experienced multiple falls over the course of several months. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB152196,5MA261,RCF,7/23/2015,"Resident #2 had a history of inappropriately touching and care planned to keep Resident #1 away from Resident #2. On or about August 11, 2015, Resident #2 was observed inappropriately touching Resident #1. The facility failed to adequately monitor Resident #2 as care planned. The failure is a violation of resident rights, is considered neglect of care resulting sexual abuse.",2,,,,Neglect +HB152030,5MA261,RCF,7/13/2015,"Resident #1 had a diagnosis of dementia and resided in a secure memory care facility. On two known occassions, Resident #1 successfully eloped from the secure building. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules.",2,,,, +HB153385,5MA261,RCF,10/30/2015,"RV2 has a history of unsolicited and inappropriate contact with other residents. RV2's care plan indicated that he/she was not to be left alone with other residents. On October 30, 2015 facility staff left RV2 in the dining room unsupervised with other residents. Facility staff returned to observe RV2 reaching under RV1's pants and rubbing his/her thigh. The facility's failure to follow RV2's care plan is a violation of the Oregon Administrative Rules, is considered neglect of care and constitutes abuse.",2,,,,Neglect +JG117137,5MA266,RCF,4/26/2011,Resident #1 did not received antibiotic medication on one occasion. No negative outcome occurred as a result. The facility failed to administer medication as prescribed resulting in the potential for harm.,2,0,,, +CO11107,5MA266,RCF,7/27/2011,"The facility failed to ensure service plans were updated after a significant change of condition, reflective of residents' current status and provided clear direction to staff regarding the provision of services for Resident #2. The facility failed to ensure significant changes of condition were evaluated, or referred to the facility RN, and failed to ensure residents were monitored consistent with their evaluated needs. The facility RN did not assess Resident #1 and #2 who experienced significant changes of conditions. Resident #1 experienced multiple, on going injury falls and was at risk for serious injury. Resident #2 experienced a significant weight loss and continued to lose weight. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +JG117602,5MA266,RCF,6/10/2011,"The facility failed to update Resident #1's Service Plan to address the resident's change of condition after exhibiting aggressive behaviors that negatively affected two known residents over a period of time. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +JG117744,5MA266,RCF,7/1/2011,The facility failed to have an accurate Medication Administration Record resulting in the resident not receiving her/his evening dose for approximately three days. There was no harm as a result of the error. The failure was a violation of OARs.,2,0,,, +JG120883A,5MA266,RCF,1/22/2012,RP2 has made multiple documented medication errors. There are no known negative outcomes as a result of the errors. The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +JG120883B,5MA266,RCF,1/22/2012,"Multiple residents required assistance with toileting needs and care planned for monitoring and changing every two hours as needed for incontinence. On multiple occasions residents were found incontinent with indications that they had been wet for an extended period of time. Resident #1 and Resident #3 had skin breakdown. The facility failed to assist with toileting needs and follow residents' care plans. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +JG120936,5MA266,RCF,3/12/2012,"The facility failed to adequately care plan for falls or refer the falls to the RN. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +JG133197,5MA266,RCF,9/12/2012,"It was reported Resident #1 went into Resident #2's room and aggressively shook Resident #1, resulting in Resident #1 becoming emotionally distressed to the point it took significant time to calm him/her down. Resident #1's aggressive behavior regarding Resident #2 began more than a month prior to the reported incident. The facility's preventative measures were insufficient, given the history of Resident #1's behaviors in past interactions with Resident #2, resulting in the facility failing to provide a safe environment for Resident #2. The facility's failures are a violation of residents rights, considered neglect of care and constitutes abuse.",2,0,Substantiated,Substantiated,Neglect +JG133140B,5MA266,RCF,7/10/2012,It was reported the facility failed to provide proper supervision for resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO13119,5MA266,RCF,8/28/2013,"A re-licensure survey completed on August 28, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to ensure an RN assessment was completed, evaluate changes of condition in order to develop appropriate interventions for Resident #2 who experienced a significant change of condition and failed to monitor residents consistent with their evaluated needs. The facility also failed to provide healthcare services in accordance with all licensing rules applicable to the facility. Resident #2 experienced severe weight loss and unrelieved pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +JG133351,5MA266,RCF,4/6/2012,"The facility failed to evaluate and monitor Resident #1 related to a change of condition, document the changes, refer to facility RN as appropriate, and update the service plan accordingly. Resident #1 first experienced a close fall complaining of pain after, and suffered a fall later in the evening again complained of pain in his/her leg. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. The Notification of Findings was completed at a later date; therefore a civil penalty was not issued due to the extended period of time between the incident date and processing by the Department.",3,,,,Neglect +JG135250,5MA266,RCF,4/27/2012,Witness #3 was in training and administered the wrong medication to Resident #1. Resident #1 was monitored with no observable negative effects. The facility failed to ensure a safe medication administration system resulting in the potential for harm.,2,,,, +JG145615,5MA266,RCF,10/10/2012,"Resident #1 was a known fall risk. The facility failed to adequately care plan surrounding falls. Resident #1 experienced a fractured hip from a fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to the timeframe between the investigation and processing by the department.",3,,,,Neglect +JG145661,5MA266,RCF,11/25/2012,"Resident #2 had a history of agitated and aggressive behaviors. The facility failed to adequately monitor Resident #2 after she/he was observed to be agitated resulting in negative behavior, affecting another resident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +JG145761,5MA266,RCF,8/14/2012,"Resident #1 experienced multiple falls with injury. The facility failed to adequately care plan for falls resulting in continued falls with injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +JG146339,5MA266,RCF,1/8/2014,RP2 was observed by two staff members to slap Resident #1. RP2 was suspended and employment terminated. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +JG134625,5MA266,RCF,8/28/2013,"The facility failed to ensure timely care plan changes related to fall interventions resulting in continued falls with inury to Resident #1. The failure is a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +JG149383,5MA266,RCF,11/20/2014,"The facility failed to evaluate, monitor and refer to the facility nurse after Resident #1 experienced a significant change of condition. Resident #1 experienced worsening of a toe sore resulting in the development of an ulcer that required treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +JG151924,5MA266,RCF,1/29/2015,"Resident #1 was a recent admit who had a history of falls. Resident #1 experienced multiple falls with injury. The facility failed to adequately care plan for falls resulting in injury to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +JG152380,5MA266,RCF,1/29/2015,"The facility failed to treat Resident #1 with dignity and respect when several staff physically restrained her/him to treat a wound. The failure is a violation of resident rights, is considered a restraint and constitutes abuse.",2,,,,Restraints +JG134609,5MA266,RCF,8/12/2013,"Resident #2 had a history of aggressive behavior and known to be territorial of her/his room. The facility failed to implement interventions to address Resident #2's behavior resulting in harm when Resident #1 entered her/his room. The failures are violations of resident rights, are considered neglect of care and constitute abuse. This notification was processed at a later date due to the timeframe between the investigation and when it was submitted to the Department.",2,,,,Neglect +JG147995A,5MA266,RCF,3/19/2014,"RV1 required assistance with dressing and facility staff were to ensure that RV1 wore his/her undergarments daily. RV1 was noted to have not worn his/her undergarments on several occasions. RV1 had a history of rashes on his/her chest and was prescribed a PRN barrier cream. The barrier cream was not used the whole month of April 2014. On April 24, 2014 RV1 was transferred to the hospital due to a red bleeding rash on his/her chest. The facility's failure to provide appropriate care is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP116351,5MA269,RCF,2/14/2011,RP2 stuck a sock in Resident #1's mouth and put a towel over her/his face while showering her/him to prevent from biting. The facility failed to protect Resident #1 from corporal punishment. RP2 was held responsible for abuse and terminated from employment.,2,0,Not Substantiated,Substantiated,Physical Abuse +GP117045B,5MA269,RCF,5/12/2011,The facility failed to properly care plan Resident #1 resulting in negative behavior affecting other residents.,2,0,,,Neglect +GP117178,5MA269,RCF,5/16/2011,"The facility failed to assess and intervene resulting in Resident #1 being hospitalized. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A combined sanction was issued with report #GP116979.",3,600,Substantiated,Substantiated,Neglect +GP116979,5MA269,RCF,5/14/2011,"The facility failed to provide a safe medication administration system resulting in Resident #1 being hospitalized. The facility did not administer blood thinning medication to Resident #1 from May 9-14, 2011. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. A combined sanction was issued with report #GP116978.",3,,,,Neglect +GP116507,5MA269,RCF,3/11/2011,RP2 was heard telling Resident #1 to shut up. The facility failed to ensure resident rights resulting in loss of dignity.,2,0,,, +GP129947,5MA269,RCF,4/28/2012,"Resident #1 had a history of agitation and aggressive behavior. On April 28, 2012, Resident #1 was visibly agitated with a resident and the facility removed the other resident. Resident #1 continued to be agitated and while a staff member was finding something to distract the resident, Resident #1 went over and slapped Resident #2 causing her/his lip to split. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO12115,5MA269,RCF,10/3/2012,"Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight regarding residents' quality of care and services. The facility failed to ensure Resident #5 was provided ADL assistance in accordance with their plan of care and failed to ensure Resident #5 was free from neglect and failed to treat him/her with dignity and respect. Resident #5 experienced unrelieved pain after being left on the toilet for 1 hour and 28 minutes. The facility failed to ensure Residents #1 and #2 were evaluated and monitored, consistent with their needs. Resident #1 was physically aggressive with multiple residents and caused injury to him/herself and others. Resident 2 had a physician order for a lactose free diet, received the wrong diet, and had a negative outcome. Facility also failed to provide an RN assessment for Resident #5, who had a significant change of condition. Resident #5 experienced severe weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,900,,,Neglect +GP121025,5MA269,RCF,9/3/2012,"The facility failed to timely assess and intervene after Resident #1 experienced a significant change of condition on or about September 3, 2012. On September 6, 2012, Resident #1 was admitted to the hospital from the physician's office for surgery to remove an infected gall bladder. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil money penalty is warrantend, however one was not issued based on a Letter of Agreement with a Restriction of Admissions that was enacted on or about October 9, 2012.",3,0,,,Neglect +GP121013,5MA269,RCF,9/10/2012,"Resident #1 appeared with unexplained bruising to his/her lip, arms and hands after receiving care from Reported Perpetrator 2 (RP2). In the area RP2 works, residents have unexplained bruising. RP2 was found responsible for physical abuse. The facility failed to protect residents from physical abuse. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Physical Abuse +GP133023,5MA269,RCF,4/12/2013,"Resident #1 was found with treated, minor wounds to his/her arms and leg. There was no documentation of how it happened or who treated the wounds. The facility failed to provide documentation regarding the change of condition and monitoring of resident #1's wounds. The failure is a violation of Oregon Administrative Rules.",2,0,,, +GP133020,5MA269,RCF,4/19/2013,"Residents #1 and #2 had an altercation, resulting in injury to Resident #1's hand. Resident #1 had a previous altercation with another resident, resulting in injury to both residents. There was no documentation indicating the facility implemented a safety plan following the first altercation. The facility failed to address Resident #1's behavior. The failure is a violation of Oregon Administrative Rules.",2,0,,, +GP121984,5MA269,RCF,12/26/2012,"Resident #1 had a history of aggressive behavior. Resident #1 and Resident #2 were involved in a physical altercation resulting in a skin tear. The facility failed to appropriately monitor behaviors. The failure is a violation of resident rights, is considered neglect of care and constiutes abuse. The facility also failed to cooperate with an investigation by not providing requested documentation. The failure is a violation of Oregon Administrative Rules.",2,,,,Neglect +GP133701,5MA269,RCF,7/5/2013,Resident #1 was care planned for Witness #2 to visit only between the hours of 9 AM to 5 PM due to previous concerns of Witness #2's behavior towards Resident #1. Witness #2 was observed to be in Resident #1's room after 5 PM. The facility failed to follow Resident #1's care plan resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +GP134648,5MA269,RCF,10/7/2013,"Resident #1 has a history of aggressive behavior. On or about October 7, 2013, Resident #1 pushed Resident #2 resulting in a head injury that required transportation to the hospital for an evaluation. The facility failed to appropriately care plan for Resident #1's aggressive behaviors resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP145584,5MA269,RCF,1/3/2014,"Resident #1 has a history of aggressive behavior and care planned to be in line of sight when out of room. Resident #1 was observed hitting Resident #2 with a cane until staff intervened. The facility failed to follow the care plan resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP135453,5MA269,RCF,12/19/2013,"Resident #1 had a history of aggressive and agitated behaviors. On two known occasions, Resident #1 struck out at Resident #2. The facility failed to appropriately care plan for behaviors resulting in altercations. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP135349,5MA269,RCF,12/10/2013,"Resident #1 and Resident #2 experienced a physical altercation resulting in skin tears/scratches. Witness testimony and facility documentation revealed both residents have had previous altercations. Investigation concluded that the facility failed to ensure a safe environment resulting in continued altercations. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP148008,5MA269,RCF,8/2/2014,"Resident #1 had a history of aggressive behavior towards other residents. On or about August 2, 2014, Resident #1 pushed Resident #2 resulting in a ""goose egg"" on the back of her/his head. The facility failed to provide adequate interventions to address Resident #1's behaviors. The failure is a violation of resident rights, are considered neglect of care and constitutes abuse. The incident ocurred prior to the change of ownership on August 29, 2014.",2,,,,Neglect +GP146746,5MA269,RCF,4/12/2014,"Resident #1 had a history of aggressive behavior and care planned to be in line of sight when out of room. Resident #1 was physically aggressive with Resident #2 on two occasions. Facility failed to ensure a safe environment, is a violation of resident rights and constitutes abuse.",2,,,,Neglect +GP147665,5MA269,RCF,7/8/2014,"Staff heard noise and responded to Resident #2's closed room where it was observed that Resident #2 was choking Resident #1 with a long sleeve shirt. Both residents have diagnoses related to cognition and histories of wandering into other residents' rooms. Resident #2 also has a known history of being upset when others enter her/his room. The facility failed to ensure a safe environment. The failure is a violation of residents rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP148229,5MA269,RCF,8/20/2014,"Resident #1 became aggressive and pushed Resident #2 resulting in a fall that required transporation to the hospital for an evaluation. Witness testimony and facility documentation revealed Resident #1 had a history of verbal and physically aggressive behavior. Care plan failed to provide interventions to address the resident's behaviors. The facility failed to adequately care plan and monitor Resident #1's behavior resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A civil money penalty is warranted due to facility's history, however one was not issued due to a change of ownership on September 1, 2014.",2,,,,Neglect +GP146260,5MA269,RCF,3/4/2014,"Resident #1 was diagnosed as cognitively impaired and identified as a high fall risk. Care Plan indicated that the resident required assistance with ADLs (Activities of Daily Living) including toileting. Resident #1 was not provided with assistance when observed ambulating with her/his walker. The facility failed to ensure the care plan was followed resulting in a fall with injury that required transportation to the hospital. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to a change in ownership on or about September 1, 2014.",3,,,,Neglect +GP146537,5MA269,RCF,3/27/2014,Resident #2 was observed kicking Resident #1 before staff separted. Witness testimony revealed Resident #2 had a history of aggressive behavior towards other residents. Resident #1's care plan did not address Resident #1's aggressive behavior until after this incident. The facility failed to ensure an accurate care plan and is a violation of Oregon Administrative Rules.,2,,,, +GP147704,5MA269,RCF,7/11/2014,"Resident #2 experienced a fall with injury that required transporation to the hospital for treatment after Resident #1 was observed by staff assisting with a transfer in the dining room. Resident #2's care plan indicated Resident #2 has an unsteady gait and required assistance with mobility. The facility failed to ensure the care plan was being followed as directed resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however not issued due to the change of ownership on September 29, 2014.",3,,,,Neglect +GP147744,5MA269,RCF,7/15/2014,"The facility failed to adequately monitor Resident #1 who was known to show aggression towards other residents. Resident #1 and Resident #2 had an altercation resulting in Resident #2 sustaining a skin tear. This failure is a violation of resident rights, is considered neglect of care, and constitute abuse.",2,,,,Neglect +GP148316,5MA269,RCF,8/29/2014,"The facility failed to monitor Resident #2 and redirect when Resident #2 prevented Resident #1 from entering his/her room. Resident #2 grabbed Resident #1's arm and pushed him/her down resulting in a fracture. This failure is a violation of resident rights, is considered neglect of care, and constitute abuse.",3,,,,Neglect +GP148448,5MA269,RCF,9/9/2014,"The facility failed to monitor Resident #3 and redirect when Resident #3 entered other residents rooms. Resident #3 entered Resident #1's room while Resident #1 was using the bathroom. No facility staff were in the area to monitor Resident #3 when the incident occurred. This failure is a violation or resident rights, is considered neglect of care and constitutes abuse.",2,,,, +GP148590A,5MA269,RCF,9/17/2014,"The facility failed to adequately monitor Resident #1 who had a history of falls. Resident #1 fell and sustained a laceration requiring staples. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +GP148590B,5MA269,RCF,9/17/2014,"The facility failed to adequately assess and intervene regarding a recent fall and Resident #2's high fall risk. Resident #2 fell again and sustained a laceration requiring staples. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +GP148590C,5MA269,RCF,9/17/2014,"The facility failed to follow Resident #3's care plan for safety checks and to lock the doors to the outside courtyards when it starts getting dark. Resident #3 was able to get outside when it was getting dark, and fell sustaining a brain injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +GP149545,5MA269,RCF,12/11/2014,"The facility failed to adequately care plan and monitor Resident #1 for his/her frequent falls. Resident #1 had an un-witnessed fall in October resulting in a hip fracture. Resident #1 fell again and sustained an arm fracture. These failures are a violation of resident rights, which is considered neglect of care and constitutes abuse.",3,400,,,Neglect +GP159820,5MA269,RCF,1/7/2015,"The facility failed to adequately monitor Resident #1 for wandering into other residents rooms, and Resident #2 for possible altercations if a resident wanders into his/her room. Resident #1 wandered into Resident #2's room and Resident #2 slapped Resident #1. These failures are a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +GP150323,5MA269,RCF,2/20/2015,"Resident #1 had money go missing from his/her cash account. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +GP151530,5MA269,RCF,6/10/2015,"The facility failed to adequately monitor Resident #2 in relation to his/her aggressive behavior. Resident #2 entered Resident #1_x001A_s room and choked Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +GP151698,5MA269,RCF,6/23/2015,The facility failed to adequately train Reported Perpetrator #2 (RP2) to ensure RP2 could adequately care for residents. RP2 inappropriately assisted Resident #1 back to his/her room. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES117353A,5ME119,RCF,6/20/2011,"Reported Perpetrator 2 (RP2) failed to reapproach or accept assistance from other staff as care planned when Resident #1 became combative while RP2 provided care. Resident #1 suffered a skin tear and bruising. During an informal conference held on 1/31/2012, RP2 provided further clarification and demonstration of the event. Resident #1 was soiled with feces and unclothed from the waist down when he/she stood and attempted to walk out of the bathroom. RP2 told Resident #1 that he/she did not have any clothes on. When he/she became combative (hitting, biting, spitting), RP2 held Resident #1_x001A_s forearms [as demonstrated in the informal conference] attempting to stop the behavior. RP2 noticed Resident #1_x001A_s arm bleeding and was successful to distract him/her from the behavior and have him/her apply a tissue to the wound. Another staff person asked RP2 if he/she need help through the closed unlocked door. RP2 declined the help in order for the other staff person to provide help to the rest of the residents. This incident occurred during the dinner mealtime. RP2 was soiled with fecal matter on his/her clothing and made a _x001A_judgment call_x001A_ to stay with Resident #1. RP2 had provided routing incontinence care to Resident #1 and this was the first incident of increased behaviors toward RP2.",2,0,Not Substantiated,Substantiated,Physical Abuse +ES118475,5ME119,RCF,11/10/2011,Resident #1 eloped from facility undetected on 11/11/11. The police returned Resident #1 to the facility with no injuries. RP2 viewed their video tapes and discovered Resident #1 walked out the door. The locked door was checked; it had malfunctioned.,2,0,,, +ES133072,5ME119,RCF,4/24/2013,Reported Perpetrator 2 (RP2) took a picture of him/her self and Resident #1. This picture was then posted on a social media site. The facility failed to assure Resident #1_x001A_s rights. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES135289,5ME119,RCF,12/2/2013,"In December 2013 Reported Perpetrator #2 (RP2) was providing care services to Resident #1. Resident #1 struck RP2 in the head, and RP2 reacted by slapping Resident #1's hand. By slapping Resident #1, RP2 is responsible for physical abuse. The facility failed ensure a safe environment. This is a violation of resident rights and Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +ES134580,5ME119,RCF,9/23/2013,"Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) placed Resident #1 in his/her room in his/her mobility device with the wheel brakes locked on several occasions. Resident #1 is not able to unlock the brakes on their mobility device and could not leave his/her room. RP2 and RP3 were found to be responsible for involuntary seclusion of Resident #1, which constitutes abuse. The facility failed to protect Resident #1 from involuntary seclusion which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Involuntary Seclusion +ES146027,5ME119,RCF,2/3/2014,Six pills of Resident #1's medication went missing from the med cart. The medications are thought to have been accidentally disposed of. The facility failed to provide a safe medication administration system resulting in medication not being accounted for. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES149603,5ME119,RCF,12/15/2014,Reported Perpetrator 2 (RP2) administered Resident #1's medications. Resident #1 would not swallow his/her medications. RP2 said to Resident #1 that he/she wanted to punch Resident #1 in the face. Resident #1 showed signs of being upset by RP2's comment. RP2 admitted making the threatening statement to Resident #1. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +ES152807,5ME119,RCF,6/1/2015,Resident #1 was scheduled to receive eye drops every night. Due to the amount of medication left it was determined that the drops had not been administered consistently. The facility failed to provide a safe medication administration system and assure the Medication Administration Record was accurate. The failures are a violation of Oregon Administrative Rules.,2,,,, +MM132982,5ME248,RCF,3/8/2013,Resident #1 was involved in an altercation with Resident #2. Resident #2 did not sustain any injuries. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB105623,70A011,ALF,10/6/2010,"A medication ""hold order"" was not completed on Resident #1's medication administration record resulting in him/her receiving two additional doses of the regularly scheduled narcotic medication.",2,0,,, +HB106005,70A011,ALF,12/29/2010,Resident #1's 8am morning medications were administered late in the morning because he/she didn't get up until late in the morning. The Facility failed to obtain a doctor's order timely for a urine sample to test for an infection.,2,0,,, +HB117692,70A011,ALF,7/19/2011,"Resident #1 had memory and cognition issues, elopement history, and was on two hour checks between the hours of 8pm and 8am. He/she successfully eloped from the facility on 5/2/11, 7/19/11, 7/25/11.",2,0,,, +HB129893,70A011,ALF,4/12/2012,Reported Perpetrator 2 knowingly accepted and cashed a check in the amount of $500 from Resident #1. RP2 is responsible for theft of money from Resident #1. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +HB120140,70A011,ALF,5/24/2012,"Resident #1 was care planned to be checked every two hours for toileting, to change him/her and apply barrier cream. On 5/24/12 during the evening time, Resident #1 was found to be soaked in urine and redness was noted on his/her buttock. The facility failed to follow his/her care plan resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB147386,70A011,ALF,6/13/2014,The facility failed to ensure Resident #1's ordered medications were administered. He/she was not administered ordered medication for approximately six days; however no negative outcome occurred. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,,,, +HB151511,70A011,ALF,6/9/2015,"On 6/8/15, Resident #1 reported missing a bottle of approximately 70 narcotic pain pills from his/her room. An investigation determined an unknown individual is responsible for the theft of his/her narcotic medications. The facility failed to ensure a safe environment to prevent theft of medications and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH147518,70A012,ALF,6/24/2014,"Multiple residents reported missing items from their respective rooms. An internal investigation was initiated and the local law enforcement notified. Investigation concluded that the facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BH148523,70A012,ALF,8/11/2014,"The facility failed to ensure a safe environment resulting in the loss of Resident #1's jewelry. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered neglect of care and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +MS117834,70A062,ALF,8/9/2011,Resident #1 discovered missing jewelry from her/his room. Resident #1's room was locked and only staff had access to the resident's room while she/he was out of the facility. The facility failed to provide a safe environment resulting in the loss of Resident #1's property. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MS117665A,70A062,ALF,8/6/2011,RP2 failed to assist residents with their required needs as care planned. The facility failed to ensure multiple residents received services as needed and is a failure of OARs. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Neglect +MS117665B,70A062,ALF,8/6/2011,RP2 was verbally abusive towards multiple residents. The facility failed to protect residents from verbal abuse and is a violation of OARs. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MS117665C,70A062,ALF,8/6/2011,RP2 roughly treated residents while providing assistance resulting in harm. The facility failed to protect residents from rough treatment and is a violation of OARs. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +MS118687,70A062,ALF,11/14/2011,"Resident #1 has a condition that requires medication twice a day to reduce shaking. On November 14, 2011 the facility ran out of the specific medication resulting in increased shaking from missing two doses. Investigation revealed the facility has been starting the resident's medication early resulting in running out before the next cycle fill. The facility failed to provide a safe medication administration system resulting in a negative effect to Resident #1. Failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS129979,70A062,ALF,5/2/2012,"Resident #1 had a medical condition that required regularly scheduled medication. Resident #1 was found in bed unable to move or speak and was transported to the hospital for treatment. Between May 3 through 6, 2012, Resident #1 did not receive her/his medication as ordered. The facility failed to provide a safe medication administration system resulting in Resident #1 being transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +MS120148,70A062,ALF,5/5/2012,"RP2 administered Resident #1 opioid analgesic medication instead of anti seizure medication on two different occasions on May 5, 2012. Resident #1 observed to be weak and tired for a few days after the incident. The facility failed to ensure a medication was administered as ordered resulting in a negative effect to Resident #1. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for neglect of care and constitutes abuse.",2,0,Not Substantiated,Substantiated,Neglect +MS133322,70A062,ALF,5/23/2013,"Witness 7 was a former employee of the facility, who had been under the suspicion of committing theft at the facility previously. Witness 7 returned to the facility and asked to visit with employees, which Witness 7 was permitted to do. While at the facility, Witness 7 entered Resident #1 and #2's rooms and money was missing following Witness 7's visits. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +MS134495,70A062,ALF,9/20/2013,Resident #1 reported Resident #2 would not allow Resident #1 to leave the laundry room until she/he hugged Resident #2. Witness testimony and facility documentation revealed Resident #2 had a history of inappropriate behavior but failed to adequately care plan to prevent future occurrences. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS145857,70A062,ALF,1/24/2014,Reported Perpetrator 2 (RP2) made inappropriate comments to Resident #1 while performing care. The facility failed to protect Resident #1 from inappropriate comments made by RP2. This failure is a violation of Oregon Administrative Rules.,2,,,, +MF146192,70A062,ALF,2/26/2014,"The facility failed to properly assist Resident #1 with bathing services. Resident #1 was only offered bathing 5 times during the month of February, and should have been offered bathing 7 times. This failure is a violation of Oregon Administrative Rules.",2,,,, +MS146962,70A062,ALF,5/2/2014,"Resident #1 reported missing jewelry from room. Investigation initiated and local law enforcement notified. Investigation was unable to locate any suspects. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was held responsible for the loss of resident property, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +MS151048,70A062,ALF,4/20/2015,"The facility failed update Resident #1's care plan when he/she returned from a rehab facility. The facility was notified from the rehab facility that Resident #1 was a high fall risk and was confused. Resident #1 sustained several falls and fractured his/her hip. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS152043,70A062,ALF,7/14/2015,"The facility failed to adequately follow Resident #1_x001A_s care plan to keep him/her and his/her room clean. Resident #1 and his/her room had a strong urine smell. Several items in his/her room had feces on them, and there were feces stains on his/her carpet for several days. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",1,300,,,Neglect +AL146687,70A069,ALF,10/23/2013,"On 10/23/13 about 8pm, Resident #1 ingested Resident #2_x001A_s medications that Reported Perpetrator 2 (RP2) left unattended in their shared room. RP2 reported the error to facility management and placed Resident #1 on alert charting throughout the night. On 10/24/13 about 5am, Resident #1 was non responsive and was transported to the ER. RP2's actions are considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system and is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +AL151429,70A069,ALF,8/8/2014,The facility failed to adequately answer Resident #1's call light in a timely manner. Resident #1 suffered several falls without injury as a result. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES105287,70A083,ALF,9/10/2010,Resident #1 discovered money missing from his/her room two days after receipt of the money. His/her room was searched to no avail and he/she had not been out of the facility since receipt.,2,0,Not Substantiated,Substantiated,Financial abuse +ES117235,70A083,ALF,6/9/2011,Medications were found missing from Resident #1_x001A_s room where he/she kept medications to self administer. Resident #1's medications were taken by an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +ES118002,70A083,ALF,9/15/2011,"Resident #1 had impaired cognition, was a known elopement risk, and had history of cutting off his/her Wanderguard. On 9/15/11, Resident #1 cut off his/her Wanderguard, successfully left the facility, and was returned unharmed by police.",2,0,,, +ES118524,70A083,ALF,11/21/2011,Reported Perpetrator 2 administered wrong medications to Resident #1.,2,0,,, +ES118458,70A083,ALF,7/7/2011,"Resident #1 had short term memory loss; lost pieces of his/her hearing aides and subsequently became unusable. The facility was responsible for putting his/her hearing aides in and out, and keeping them secure at night.",2,0,,, +ES128907,70A083,ALF,12/21/2011,Resident #1 was observed in pain at approximately 4:15am; however Reported Perpetrator 2 (RP2) did not administer the pain medication until 5:00am. RP2 neglected to timely administer pain medication resulting in Resident #1 suffering continued pain. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Neglect +ES118477,70A083,ALF,11/15/2011,"Resident #1's care plan was not followed when Reported Perpetrator 2 did not place a pressure alarm under him/her at bedtime. The care plan did not provide clear instruction. Resident #1 got up the following morning, attempted to get up on his/her own, and fell with no injuries. The facility failed to follow Resident #1's care plan and the failure is a violation of Oregon Administrative Rules.",2,0,,, +ES121938,70A083,ALF,3/22/2012,The facility failed to follow Resident #1's care plan resulting in his/her care not provided appropriately. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES135449,70A083,ALF,12/2/2013,"Reported Perpetrator 2 (RP2) failed to check Resident #1 twice during the night hours as required in his/her care plan. Resident #1 was found by morning shift staff and he/she has suffered an injury from a fall. RP2's failures are considered neglect of care and constitute abuse. The facility failed to provide a safe environment and failed to self-report the incident, and the failures violate Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +ES148865,70A083,ALF,10/9/2014,The facility failed to adequately intervene in relation to Resident #1 frequently falling out of his/her wheelchair. Resident #1 continued to sustain falls out of his /her wheelchair when other residents pushed him/her. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES150227,70A083,ALF,2/8/2015,"The facility failed to administer medication as ordered to Resident #1. Resident #1 was given three times his/her prescribed dose and sustained falls requiring hospital care as a result. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES150645,70A083,ALF,3/22/2015,The facility failed to adequately follow Resident #1's care plan calling for 2 person assistance with transfers. Facility staff have transferred Resident #1 with only on care provider. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES150599,70A083,ALF,3/12/2015,The facility failed to adequately monitor Resident #1 given his/her history of wandering and attempting to help care for other residents. Resident #1 was found in Resident #2's room and his/she tried to pull Resident #2 out if his/her bed. This failure is a violation of Oregon Administrative rules.,2,,,, +ES151572,70A083,ALF,6/11/2015,"The facility failed to adequately monitor Resident #1 and Resident #2. The residents were involved in an altercation with each other, and Resident #1 was hit. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES150881,70A083,ALF,4/8/2015,The facility failed to adequately provide shower service. Resident #1 went several days without showering as a result. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES152680A,70A083,ALF,9/1/2015,"Resident #1 had several pairs of pants go missing. The pants were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES152680B,70A083,ALF,9/1/2015,The facility failed to provide Resident #1 shower service. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES153239,70A083,ALF,10/1/2015,"The facility failed to provide a safe medication administration system in relation to In incorrect medication increase for Resident #1. The medication error occurred for several days and Resident #1 experienced increased behaviors. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES153954,70A083,ALF,12/12/2015,"Residenst #1 and #2 had money go missing from their room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Residents #1 and #2 property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +OR0000991300,70A083,ALF,8/11/2015,,0,,,Substantiated, +CO13126,70A102,ALF,10/16/2013,"The Facility failed to provide effective administration oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed October, 16, 2013.",3,0,,,Neglect +OT151284B,70A102,ALF,5/11/2015,Resident #1's care plan stated that Witness #5 was to be called if he/she refuses medications. Resident #1 refused medication and Witness #5 was not contacted. The facility failed to follow Resident #1's care plan regarding him/her refusing to take medications. The failure is a violation of Oregon Administrative Rules.,2,,,, +OT152970,70A102,ALF,9/9/2015,Resident #1 was having anxiety and some hallucinations when medication was requested. Resident #1 had a PRN medication prescribed every two hours for anxiety. Reported Perpetrator 2 (RP2) failed to provide a PRN anxiety medication to Resident #1 upon request. Medication was administered approximately two hours after the original request. RP2 was found responsible for neglect which constitutes abuse. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +BH121856,70A200,ALF,12/5/2012,Resident #1 reported $40.00 missing from his/her apartment. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BH132906,70A200,ALF,3/4/2013,Resident #1 reported money missing from his/her wallet. The facility set up a camera and caught Reported Perpetrator 2 (RP2) taking cash from Resident #1_x001A_s wallet. RP2 was found responsible for the theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BH133256,70A200,ALF,5/6/2013,"The facility reversed a physician's order for Resident #1. When the error was discovered, the physician ordered a medication to be given to Resident #1 until he/she lost six pounds. The facility continued the medication for four days after the six pound loss. Resident #1 was admitted to the hospital and diagnosed with dehydration and acute renal failure. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC116850,70A209,ALF,4/20/2011,"On 3/3/11, Resident #1's money was placed securely in his/her locked drawer in his/her apartment. When he/she noticed that the key was accidentally left in the lock, he/she locked the drawer, removed the key but did not check that the money was there. On 4/25/11, he/she discovered the money missing. Resident #1 did not have visitors during this time; however staff had access to his/her room but all deny taking the money or observing the key in the lock. Resident #1's money was taken by an unknown individual.",2,0,Not Substantiated,Substantiated,Financial abuse +BC121684,70A209,ALF,11/4/2012,Resident #1's laptop was stolen from his/her room. He/she kept the door locked when not in the room. An unknown individual is responsible for the theft of Resident #1's laptop. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated, +CO14009,70A209,ALF,12/13/2013,"The Facility failed to evaluate and monitor Resident #3 related to changes of conditions, document the changes, refer to the facility RN as appropriate and update service plans accordingly. Resident #3 experienced two injury falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC134815,70A209,ALF,8/9/2013,"The Facility failed to maintain a safe medication administration system to ensure Resident #1_x001A_s narcotic medication was available to administer. Resident #1 went without narcotic pain medication for approximately three (3) days resulting in pain and being sent to the hospital emergency room for medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB117007,70A214,ALF,5/18/2011,"A Facility staff member, Reported Perpetrator #2 (RP2) was suspected of taking a bottle of narcotic medications belonging to a Facility resident. The Facility was not able to conclusively determine that RP2 was responsible for the missing medication.",2,0,,,Neglect +HB129689,70A214,ALF,3/31/2012,RP2 (Reported Perpetrator 2) took Resident #1_x001A_s blood pressure and was rough with him/her while doing so. RP2 was found responsible for abuse. The facility failed to provide a safe environment for Resident #1. RP2 was known by staff to be impatient at times. The failure is a violation of resident rights and constitutes physical abuse.,2,0,Substantiated,Substantiated,Physical Abuse +HB151691,70A214,ALF,6/23/2015,"On or about June 19, 2015 Reported Perpetrator #2 (RP2) administered numerous medications to Reported Victim #1 (RV1) in error. Approximately two hours later RV1 began to suffer side effects of the medication error in the form of bowel problems, nausea and vomiting. RV1 was transported to the hospital. The facility failed to provide a safe environment for RV1.",2,,Not Substantiated,Substantiated,Neglect +BC134754,70A246,ALF,10/13/2013,"Resident #1's Service Plan stated he/she was to wear Geri Sleeves at all times, due to thin, fragile skin. Reported Perpetrator 2 (RP2) transferred Resident #1 without Geri Sleeves, resulting in a skin tear to Resident #1's elbow. RP2 stated he/she was aware Resident #1 was to wear Geri Sleeves at all times. The facility failed to follow Resident #1's Service Plan. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for neglect of care, which constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +BC133977,70A246,ALF,7/6/2013,"The facility failed to care plan appropriately and implement interventions for Resident #1_x001A_s falls due to his/her known behavior of removing alarms. Resident #1 fell and suffered a broken femur. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH116405,70A259,ALF,2/22/2011,Resident #1 did not wake up to take his/her medications at 6:30am; however Witness 6 charted the medication as having been given.,2,0,,, +BH145970,70A259,ALF,1/31/2014,"Resident #1 reported money missing about 1/31/14 and again about 3/18/14. Reported Perpetrator 2 (RP2) is responsible for the theft of money, and additionally the theft of Resident #2's ring, which constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BH146505,70A259,ALF,3/25/2014,"It was discovered that Resident #1 had money missing from his/her wallet. The investigation determined Reported Perpetrator 2 (RP2) was a person of interest; however there was not enough evidence to find RP2 responsible, thus an unknown individual is responsible for the theft of money. The facility failed to provide a safe environment and the failure is a violation of resident rights.",2,,Not Substantiated,Substantiated,Financial abuse +BH145605,70A259,ALF,1/4/2014,"Resident #1's care plan required a two person transfer described as a fall risk. On or about January 4, 2014, Resident #1 fell and sustained injury after RP2 attempted to transfer Resident #1 on her/his own. The facility failed to ensure adequate staffing after an increase in resident care needs due to a viral outbreak. The facility failed to ensure the care plan was followed. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,Substantiated,Substantiated,Neglect +BH150733,70A259,ALF,3/22/2015,"RP2 was providing shower care when Resident #1 slipped resulting in skin injury. Investigation revealed Resident #1's normal care giver when providing care uses a shower chair, however this information was not relayed to RP2 or written on the care plan. The facility failed to ensure an accurate care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH153753,70A259,ALF,3/21/2015,There was a reported concern that RP2 was spending too much time with Resident #1. Investigation determined that RP2 was having an emotionally inappropriate relationship with Resident #1. The facility failed to ensure a safe environment resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +SV104006,70A260,ALF,4/8/2010,The facility failed to have a safe and secure medication administration system when ongoing discrepancies were occurring in the count of narcotic medications. Residents were not without medications and all missing medications were replaced.,2,0,,, +SV116577A,70A260,ALF,3/19/2011,"Staff failed to administer medications as ordered Resident #1, Resident #2 and Resident #3.",2,0,,, +SV116577B,70A260,ALF,3/19/2011,"Staff failed to change Resident #5 into night time clothes resulting in him/her staying awake all night, and then falling asleep the next morning, missing his/her breakfast.",2,0,,, +MV116699,70A260,ALF,4/6/2011,"The facility failed to administer medications and treatments per physician's orders, and had incomplete Medication Administration Records. Resident #2 did not receive his/her eye drops as scheduled or medication patch changed as ordered.",2,0,,, +CO11102,70A260,ALF,5/19/2011,"The facility failed to ensure investigations were completed or thorough for Resident #6 who experienced on-going falls. The Facility failed to ensure significant changes of condition were evaluated, or referred to the facility RN, and failed to ensure residents were monitored consistent with their evaluated needs. Resident #6 experienced approximately 17 falls and Resident #9 experienced skin breakdown. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +SV117152,70A260,ALF,6/2/2011,"Resident #1 and Resident #2 separately reported money missing from their own respective rooms. The facility failed to repair Resident #2's door lock timely, resulting in access to unknown persons to take his/her money.",2,0,,,Financial abuse +CO11113,70A260,ALF,8/5/2011,"The Facility failed to ensure an RN assessment was completed for Resident #4 who experienced a significant change of condition. Resident #4 experienced a severe weight loss. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +SV117444,70A260,ALF,7/11/2011,Resident #1 discovered money missing from his/her wallet in his/her room. The room was searched to no avail. The theft of money occurred as a result of an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +SV117955A,70A260,ALF,9/6/2011,Facility staff failed to report Resident #1's daily medication refusals to his/her physician and facility management. The refusal put Resident #1 at risk for an increased medical condition.,2,0,,, +SV117955B,70A260,ALF,9/6/2011,"The facility failed to respond to Resident #1's falls by adjusting his/her care plan, including reviewing possible interventions.",2,0,,, +SV118193,70A260,ALF,10/10/2011,"Reported Perpetrator 2 and Reported Perpetrator 3 admitted to not counting the narcotics at shift change, but signed the count verification form as if they had. A narcotic card was missing from the cart for Resident #1; however he/she was self managing his/her narcotic pain medication and the medication was located in his/her room. The facility failed to provide a safe medication administration system resulting in potential for harm. + + + +The Notification of Findings was completed at a later date due to the extended period of time between the incident date and processing by the Department.",2,0,,, +SV118187,70A260,ALF,9/16/2011,"Reported Perpetrator 2 (RP2), a night shift caregiver, was found asleep on Resident #2's couch. RP2 admitted to being sleepy, but denied taking Resident #1's sleep aide medication. The facility failed to keep an accurate Medication Administration Record for Resident #1 rendering it unable to determine if there was a miscount of medication.",2,0,,, +SV129151,70A260,ALF,2/1/2012,"Reported Perpetrator 2 (RP2) left Resident #1's medication cup in his/her room and failed to observe him/her take his/her 8pm medications. At 2am, staff found the cup of medications and noticed two of his/her narcotic medication pills were switched with over-the-counter pills, however RP2 denied taking them. The theft of two narcotic pills was a result of an unknown individual. The facility failed to provide a safe environment and safe medication system and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +SV129537,70A260,ALF,3/15/2012,"Resident #1 reported two rings missing. An unknown individual is responsible for the loss of his/her rings. The facility failed to provide a lockable storage space for his/her safekeeping, and also failed to immediately report this incident to the local law enforcement. The failures are a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +MV120692,70A260,ALF,7/29/2012,"Resident #1 had a history of leaving the facility and becoming lost; and he/she was care planned for staff to escort/assist with walks outside the facility. On 7/29/12 after breakfast, Resident #1 was found a convenience store down the street approximately two blocks away. The facility failed to follow his/her care plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MV146800,70A260,ALF,3/27/2014,"Resident #1 was not administered prescribed medications from 3/27/14-3/30/14 causing distress to him/her. The facility failed to ensure medication was available to administer as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DA147702,70A260,ALF,7/11/2014,The facility failed to ensure all of Resident #1's medications were given to his/her family when out of the facility between 7/2/14-7/8/14. Two of his/her medications were not included. There was no observable negative outcome. The facility_x001A_s failure is a violation of Oregon Administrative Rules.,2,,,, +CO14208,70A260,ALF,9/4/2014,"The facility failed to ensure physicians_x001A_ orders were followed. Resident #2 was sent to the emergency department and diagnosed with an infection. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV148676,70A260,ALF,9/23/2014,"Resident #1 was care planned for staff to provide stand-by assistance for ambulation. Resident #1 fell on 9/23/14 while not being provided with stand-by assistance. The facility failed to follow Resident #1's care plan resulting in a fractured arm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV146731,70A260,ALF,4/2/2014,Resident #1 sustained bruising on his/her legs from having Ted hose being fitted onto his/her legs. Resident #1 received care by RP2 and other caregivers. Resident #1 felt Reported Perpetrator 2 (RP2) was not compassionate and sensitive when fitting Ted hose on him/her. The facility failed to ensure a safe environment was provided to Resident #1 and is a violation of Oregon Administrative Rules.,2,,,, +DA150355,70A260,ALF,2/11/2015,"On 2/11/15, it was discovered that approximately 61 narcotic medications for Resident #1 were unaccounted for. The facility failed to provide a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation, which constitutes abuse.",2,,,,Financial abuse +MV153370,70A260,ALF,10/31/2015,"On 10/31/2015, Reported Perpetrator 2 (RP2) administered a dose of medication to Resident #1 that was ten (10) times the dose ordered by his/her physician. Resident #1 felt ill and experienced vomiting and diarrhea, and was transported to the hospital for treatment. The facility failed to ensure safe medication administration which violates Oregon Administrative Rules. RP2_x001A_s actions were neglectful, which constitute abuse.",3,,Not Substantiated,Substantiated,Neglect +HB116129,70A261,ALF,1/12/2011,"Resident #1 decided to discontinue self medicating and allow the facility to manage medication administration. During the course of obtaining medication orders, there was one medication left off the routine list and he/she did not receive this medication for five days; however he/she did not experience a negative outcome.",2,0,,, +HB116428,70A261,ALF,2/24/2011,Resident #2's medication order change was transcribed on Resident #1's MAR resulting in Resident #2 not receiving the increased medication dose and Resident #1 receiving a decrease in medication dose for approximately 14 days when the facility discovered the error. Neither resident experienced a negative health outcome as a result to the error.,2,0,,, +HB129574,70A261,ALF,3/18/2012,"Resident #1 was care planned requiring the use of a gait belt for all transfers. Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) did not use a gait belt when transferring Resident #1 resulting in a fall and injury to his/her knee, and later transported to the hospital for treatment. RP2 and RP3 failed to follow Resident #1's care plan resulting in injury and found responsible for neglect. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Neglect +HB146101,70A261,ALF,2/18/2014,"Resident #1 and Resident #2 had known aggressive behaviors towards other residents and each other. On or about 2/15/14, Resident #1 and Resident #2 had a physical altercation resulting in injuries. The facility failed to implement effective interventions and monitor the residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB150401A,70A261,ALF,2/26/2015,Resident #1 had a history of attempting to give money to facility staff by several different means. Reported Perpetrator 2 (RP2) asked Resident #1 for $100 to help his/her child get new tires. RP2 accepted the money. RP2's actions are considered financial exploitation which constitutes abuse. The facility is responsible for the overall conduct of staff. The failed to provide a safe environment and violates Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Financial abuse +HB150989,70A261,ALF,4/17/2015,"Resident #1 reported his/her ring was missing from his/her room. Witnesses denied taking the ring. An unknown individual is responsible for the theft of Resident #1's ring, which constitutes financial exploitation. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +MM105922,70A262,ALF,12/11/2010,"The facility failed to meet appropriate staffing standards to meet the scheduled and unscheduled needs of residents resulting moderate harm. Resident #1 fell and sustained a pelvic fracture after attempting to self transfer. The failure is violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM117894,70A262,ALF,8/25/2011,"Staff observed Resident #1 visibly agitated and arguing with RP2. RP2 swatted Resident #1 on the behind, making the resident more agitated. The facility failed to ensure Resident #1 was treated with respect and dignity. RP2 was found responsible for emotional and physical abuse.",2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +MM118106B,70A262,ALF,8/28/2011,"Facility staff left the resident unclothed waiting for assistance after a staff member was called away. The facility failed to communicate necessary information resulting in neglecting to assist Resident #1. The facility also failed to ensure Resident #1's call light was properly working resulting in numerous occassions of not receiving assitance and resulting in the potential for harm. The failures are violations of resident rights, are considered neglect of care and constitues abuse.",2,0,,,Neglect +MM121702,70A262,ALF,11/16/2012,"Resident #1 reported $600 cash missing from locked cabinet in room between October and November 2012. Facility investigation was initiated and proper agencies notified, however un able to identify suspects. The facility failed to provide a safe environment. An unknown individual was held responsible for financial exploitation and constitutes abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +MM145999,70A262,ALF,2/5/2014,"The facility failed to administer Resident #1's blood pressure medication as ordered. Resident #1 went three days without his/her prescribed blood pressure medication, and had documented high blood pressure during that time. This failure is a violation of Oregon Administrative Rules.",2,,,, +MM147616,70A262,ALF,6/27/2014,"Resident #1 had a ring go missing. An unknown individual was found responsible for taking the ring which is theft of property, is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +GB146658,70A263,ALF,1/14/2014,"Resident #1 was considered a fall risk and had multiple falls while at the facility. Resident #1 sustained injuries and was transported to the hospital multiple times. There were no amendments to his/her service plan after each fall. The facility failed to report Resident #1's falls to APS or complete incident reports; failed to update his/her service plan to address fall interventions and assess for a change of condition; failed to complete an RN assessment; and failed to have adequate staffing. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,2500,,,Neglect +GB146851,70A263,ALF,4/22/2014,Resident #1 reported $200.00 missing from his/her wallet. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The facility also failed to complete an internal investigation regarding the missing money. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Not Substantiated,Financial abuse +GB147472,70A263,ALF,4/29/2014,Resident #1 became upset when he/she was denied medication that he/she had already taken. Resident #1 grabbed Witness #1's shirt and was verbally inappropriate with Resident #2 and Resident #3. No injuries were sustained. Resident #1 had a history of demanding medication and becoming upset when denied. The facility failed to update Resident #1's service plan regarding behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +GB147988,70A263,ALF,5/24/2014,Resident #1 reported $60.00 missing from his/her wallet that was in their lockbox. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +GB147715,70A263,ALF,7/2/2014,Resident #1 reported $15.00 missing from his/her wallet. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,250,Not Substantiated,Substantiated,Financial abuse +GB148472,70A263,ALF,9/2/2014,Resident #1 reported $50.00 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +GB148870,70A263,ALF,10/8/2014,Resident #1 reported $84.00 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +GB159857,70A263,ALF,1/5/2015,"The facility failed to adequately care plan after Resident #1 was evaluated and moved into the facility. Facility failed to have adequately trained staff and equipment to meet Resident #1's care needs. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +BC117234,70A264,ALF,6/8/2011,A resident of the Facility was accidentally administered medication belonging to another resident. The staff member immediately recognized the error; however the resident had already ingested the medication. The resident experienced minor harm as a result of receiving another resident_x001A_s medication.,2,0,,,Neglect +CO12005,70A264,ALF,12/2/2011,"The Facility failed to evaluate and monitor Resident #2_x001A_s change of condition; resulting in him/her suffering a wound that worsened. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC120876,70A264,ALF,8/1/2012,"Resident #1 reported that Reported Perpetrator 2 (RP2) was rough with him/her while providing care in the night, and he/she cried out and bruising was discovered the next morning at 6am. Although Resident #1 repeated this incident consistently to several people; he/she also stated it was the last person who helped him/her that night. According to the checklist for the caregivers, RP2 last helped Resident #1 at 10:30 pm. Another staff person stated they helped Resident #1 around midnight, even though they did not sign the checklist. RP2 denied any rough treatment. It cannot be determined if RP2 is found to be responsible for physical abuse resulting in bruising to Resident #1. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +BC147943,70A264,ALF,6/25/2013,"Complainant reported multiple checks totaling over $62,000 was written out to RP2, three of the checks were written out to RP3 totalling more than $2,000. Local law enforcement was notified and an investigation was initiated. Witness testimony and facility documentation revealed RP2 had written out more than 100 checks to her/himself over the course of several months. An audit of the PIF (Personal Incidental Funds) accounts found that several residents' monies were unaccounted for. The facility failed to ensure a safe environment resulting in the loss of residents' money. The failure is a violation of Oregon Administrative Rules. RP2 and RP3 were found responsible for theft of money, is considered financial exploitation and constitutes abuse.",4,,Not Substantiated,Substantiated,Financial abuse +BC151271,70A264,ALF,5/8/2015,"The facility failed to ensure a safe medication administration system resulting in the potential for harm to Resident #1. Facility staff were unable to locate a specific medication when Resident #1 requested it and substituted a Tylenol. Resident #1 was monitored and found sleeping without complaints. The following morning, Resident #1 complained of pain and was sent to the hospital where she/he later passed away. Investigative details determined that the failure to administer the correct medication was not related to Resident #1's death. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14068,70A265,ALF,2/4/2014,"The Facility failed to provide effective administrative oversight to ensure residents_x001A_ quality of care and services, as evidenced in survey findings. The facility failed to ensure service plans were reflective of current needs and failed to follow service plans, resulting in Resident #1 experiencing pain and discomfort. The facility failed to provide a safe medication administration system with adequate professional oversight, which placed residents at risk for harm due to medication errors; as well as failing to ensure physician_x001A_s orders were carried out as prescribed placing Resident #4 at risk for harm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NW135495,70A265,ALF,7/24/2013,"The Facility failed to ensure Resident #1_x001A_s pain medication was available to administer to him/her as prescribed. Resident #1 was not administered pain medication five times over a two day period. He/she suffered ongoing pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO14102,70A265,ALF,5/29/2014,See License Condtion #ALFCD14-002,3,0,,,Neglect +NW148924A,70A265,ALF,9/19/2014,The facility failed to administer Resident #1's narcotic pain medication as ordered. The facility's failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +CO13023,70A266,ALF,2/17/2013,"A re-licensure survey completed on February 27, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: The facility failed to conduct an RN assessment and evaluate or update the service plan for Resident #3 who experienced a significant change of condition. Resident #3 lost a significant amount of weight. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +GP133628,70A266,ALF,6/27/2013,"Various amounts of money was taken from Resident #1-4's apartments between 06/15/13 and 06/23/13. The facility was unable to determine who took the money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +GP147468,70A266,ALF,6/20/2014,Resident #1 was administered another resident's medication in error. He/she was placed on checks throughout the night for side effects. He/she complained of a headache and nausea. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +GP146302A,70A266,ALF,3/10/2014,Resident #1 reported jewelry missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +GP146302B,70A266,ALF,3/10/2014,Resident #1 reported items missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +CO15199,70A266,ALF,9/23/2015,"A re-licensure survey completed on July 8, 2015, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: + + + +The facility failed to follow physician_x001A_s orders for three residents. Resident #3 experienced pain with a UTI and did not receive antibiotics for eleven days after the infection was confirmed. Resident #5's wound care dressing was removed from his/her leg. Resident #1's medication parameters were not being followed. The facility failed to provide a safe medication administration and treatment system. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +GP153189,70A266,ALF,10/19/2015,"Resident #1, Resident #2, Resident #3 and Resident #4 all had items stolen from their rooms. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM105857,70A267,ALF,10/11/2010,The facility failed to appropriately assess and intervene after Resident #1 experienced multiple non-injury falls over the course of her/his stay at the facility. The facility failed to put in appropriate interventions on a resident with memory impairment. The failures are violation of Oregon Administrative Rules.,2,0,,, +MM116395A,70A267,ALF,2/1/2011,"Two Facility residents who went on a Facility outing were left at a concern by their own request. When the residents were ready to leave, the Facility would not come back to pick them up. The residents received a ride back to the Facility with a stranger. Neither resident experienced any harm.",1,0,,, +MM116395B,70A267,ALF,2/1/2011,"A resident of the Facility with no known history of cognitive impairments or unsafe smoking habits was observed to have begun smoking in his/her room at the Facility. The Facility eventually issued the resident a move out notice due to the behavior, however it was later discovered the resident had a UTI, which most likely was the cause of the resident's behavior.",1,0,,, +MM116395C,70A267,ALF,2/1/2011,"A resident of the Facility did not receive physician ordered blood pressure medication for approximately 2 days, and on the third day received it late. Another resident had requested to be checked for a UTI but staff failed to fulfill that request. When they did, staff let the sample go bad before it could be tested. A considerable amount of time went by before a sample was tested and confirmed the resident did in fact have a UTI.",2,0,,, +MM116395D,70A267,ALF,2/1/2011,"The Facility failed to adequately staff the Facility with caregivers resulting in residents not receiving needed services. As a result, some residents experienced severe episodes of incontinence as well as pain associated with medical conditions.",2,0,,,Neglect +MM116395E,70A267,ALF,2/1/2011,"Facility staff failed to assess numerous residents' needs and put in place appropriate interventions resulting in the decline and injury. The residents experienced numerous falls, some resulting in injury and some which required hospitalization and eventually alternate placement.",2,0,,,Neglect +CO11072,70A267,ALF,5/25/2011,see file.,3,0,,,Neglect +MM116684,70A267,ALF,3/27/2011,"A resident of the Facility was awakened in the middle of the night to receive incontinence care. The resident was known to object to care at this hour and would become verbally aggressive with care giving staff. A Facility staff member, Reported Perpetrator #2 (RP2) became abusive towards the resident in response to the resident's known behaviors. The Facility was aware of RP2's tendency to be verbally aggressive with residents. RP2 was also noted to slap the resident on his/her bottom twice during the exchange.",2,0,Substantiated,Substantiated,Neglect +MM116966,70A267,ALF,4/19/2011,"A Facility staff member was found to have made verbally threatening remarks to a resident of the Facility. Following the incident an incident report was completed, however it was not available for review at a later date and the Facility did not consider the incident to be an incident.",2,0,,,Verbal/Mental abuse +MM116970,70A267,ALF,4/21/2011,"While awaiting orders to discontinue a medication, the Facility RN instructed staff to indicate that a resident refused wanted medication when the resident did not refuse the medication, and was upset that he/she was no longer going to be receiving the medication. The Facility falsified a residents MAR (medication administration record).",1,0,,, +MM118581,70A267,ALF,11/30/2011,Resident #1 required hands on bathing assistance with showers. Resident was receiving stand by assistance or staff would leave and not come back. Resident #1 got scared showering self and stopped getting them. The facility failed to follow the care plan and failed to address Resident #1's refusal for showers resulting in inadequate hygiene.,2,0,,,Neglect +MM118761,70A267,ALF,12/19/2011,"Resident #1 eloped from the facility on December 19, 2011 and again on January 11, 2012. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM120236,70A267,ALF,5/8/2012,"Resident #1, #2 and #3 all reported money missing from their apartments. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MM128994,70A267,ALF,1/17/2012,Resident #1 self administers his/her own medication and has liquid Methadone that is kept in his/her locked drawer in his/her apartment. He/she keeps the key around his/her wrist. He/she left the keys on the windowsill when Reported Perpetrator 2 (RP2) came in to assist him/her. RP2 was the only one that had been in Resident #1_x001A_s room that morning. Resident #1 noticed he/she was missing two syringes of Methadone. RP2 was found to have possession of one of Resident #1_x001A_s missing syringes of Methadone. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MM134225,70A267,ALF,8/24/2013,It was reported that Reported Perpetrator 2 (RP2) accepted items from Resident #1. Resident #2 was missing money from his/her wallet. A camera had been set and showed RP2 entering Resident #2_x001A_s room and taking his/her purse/bag into the bathroom while Resident #2 slept. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules,2,,Not Substantiated,Substantiated,Financial abuse +MM134191,70A267,ALF,8/21/2013,"Resident #1's Admission Order for medication stated he/she was to receive one x 1mg tab of a certain medication at noon and 2 mgs at bedtime. Reported Perpetrator 2 (RP2) recorded the order in the Medical Administration Record as one x 2mgs at noon two x 2mgs at bedtime. The medication dosage was doubled; Resident #1 ran out of the medication for 7 days and was reported to have withdrawal symptoms; vomiting and nausea. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for neglect of care, which constitutes abuse.",3,,Not Substantiated,Substantiated,Neglect +MM146860,70A267,ALF,4/9/2014,Resident #1 reported a metal lockbox containing $350 to $375 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MM148888,70A267,ALF,9/18/2014,"Reported Perpetrator 2 (RP2) administered Resident #1 medication that belonged to another resident. Resident #1 was transported to the hospital when he/she started showing symptoms of stomach cramps, nausea, dizziness and low pulse. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +MM149301,70A267,ALF,10/28/2014,Resident #1 was not administered his/her scheduled Morphine upon returning from the hospital. At 4:40 am the next morning Resident #1 was in severe pain. Resident #1 was administered Morphine at that time. Resident #1 did not have a PRN prescription or a physician's order. Resident #1 did not experience a negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM159930,70A267,ALF,1/12/2015,"Resident #1 was found to be incontinent and not turned frequently which lead to skin breakdown. The Hoyer lift was inoperable due to having missing parts. The facility failed to service plan appropriately for Resident #1 due to the need to be turned every two hours or upon entrance to his/her room. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM153320,70A267,ALF,10/26/2015,Resident #1 was given another resident's medication in error. Resident #1 was transported to the hospital as a precaution but was not admitted. Resident #1 did not suffer any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM154056,70A267,ALF,12/21/2015,Resident #1 reported that Reported Perpetrator 2 (RP2) purposely hit his/her head against the wall in his/her bathroom. Resident #1 sustained a skin tear on the top of his/her head. The investigator found a visible mark on the wall in the area where Resident #1's head contacted the wall. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +MM154048,70A267,ALF,12/23/2015,"Resident #1 had a prescription for a pain patch. It was discovered that the patch had not been changed on two occasions. Resident #1 experienced pain as a result. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB116453,70A268,ALF,2/9/2011,"On 2/9/11 and 2/16/11, Resident #1 was administered Resident #2's medications. His/her physician was notified and he/she did not suffer ill effects.",2,0,,, +HB116814,70A268,ALF,4/21/2011,"The facility failed to provide a safe medication administration system. Reported Perpetrator 2 administered another residents_x001A_ medication to Resident #1 resulting in hospitalization. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,Substantiated,Substantiated,Neglect +HB116884,70A268,ALF,3/7/2011,The Facility failed to provide a safe environment and implement new interventions when Resident #1 experienced three falls between 3/7/11 and 4/15/11. The 4/15/11 fall resulted in cuts to Resident #1_x001A_s hand and head.,12,0,,,Neglect +HB116828,70A268,ALF,4/24/2011,"Resident #1 had a diagnosis that required a special diet and daily medication. Resident #1 ate a restricted food item at a time without supervision resulting in higher lab levels, medication adjustment and monitoring.",2,0,,, +HB116890B,70A268,ALF,5/3/2011,Resident #1 did not receive his/her regular morning dose of medication; however suffered no ill affects. The medication was later found with another resident's medication.,2,0,,, +HB118700,70A268,ALF,12/14/2011,"On 11/30/11, Resident #1 expressed pain and a sample was obtained. On 12/2/11 an infection was confirmed and his/her physician ordered a medication for treatment. Resident #1 did not receive his/her medication until 12/8/11. The facility failed to follow-up and timely provide medication to Resident #1 resulting in continued pain and suffering. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB132251,70A268,ALF,1/28/2013,"Resident #1 was administered the wrong medications the morning of 1/26/13 and it was immediately reported to facility management and Resident #1's physician. The facility followed physician's orders to monitor and when his/her condition, he/she was taken to the hospital for evaluation and returned later in the day. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",0,0,,, +HB132877,70A268,ALF,3/21/2013,"Resident #1 was not administered his/her prescribed medication for three (3) months. Once error was discovered, he/she was administered the medication which resulted in a change of health status and transportation to the hospital for treatment. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB133203,70A268,ALF,2/19/2013,"It was reported an unknown person took an i-pad from Resident #1's apartment and a substantial amount of money from Resident #2's apartment. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the items, which is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +HB134364,70A268,ALF,9/10/2013,"Resident #1's wallet was discovered missing from his/her apartment with $50.00 cash and identification in it. Resident #1 had to have his/her social security and identification documents replaced. Resident #1 had no history of misplacing his/her wallet and his/her cognition was not compromised at the time. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the wallet, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB134147,70A268,ALF,8/15/2013,"Facility medication aids were training a new staff when it was discovered many PRN (as needed) pain medications belonging to Residents #1-5 were missing. Reported Perpetrator 2 (RP2) admitted to taking 155.5 pills from the residents. Medication aids stated they hadn't been counting the PRN medications each shift, as they trusted each other and they were medications all five residents had not requested in at least thirty days. No resident went untreated for pain. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for the theft of the medications, which is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +HB134060,70A268,ALF,8/4/2013,The facility had a power outage for approximately 1 1/2 - 2 hours. During that time Resident #1 used his/her call light because he/she had to use the restroom. The facility was short one staff in addition to the power outage and Resident #1 was not checked on and became incontinent. The facility failed to answer Resident #1's call light in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB134588,70A268,ALF,10/2/2013,"Reported Perpetrator 2 (RP2) admitted to taking $110.00 from Resident #1's apartment. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for taking the money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB151143,70A268,ALF,5/4/2015,"Reported perpetrator #2 (RP2) failed to follow Resident #1's care plan which indicated Resident #1 was a two person assist for transfers. RP2 attempted to transfer Resident #1 him/herself and Resident #1 sustained a fall with injury. RP2 is responsible for neglect of care, which constitutes abuse. The facility failed to provide a safe environment for Resident #1. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +DL120767,70A269,ALF,8/1/2012,Resident #1 had poor skin integrity. He/she had pressure sores which were caused by sitting in incontinence. Resident #1 consistently refuses care and gets aggressive if care is pursued. Resident #1_x001A_s care was more than caregivers would normally provide. The facility failed to provide appropriate skin care for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DL121424,70A269,ALF,10/23/2012,Resident #1 reported that Reported Perpetrator 2 (RP2) was rough and impatient when assisting him/her with getting TED hose on and to the restroom. Resident #1 requested to put on his/her shoes before going to the bathroom due to pain when walking without shoes. Resident #1 was told he/she could walk to the bathroom without shoes. RP2_x001A_s actions caused Resident #1 discomfort. RP2 did not respect Resident #1_x001A_s right to direct his/her own care. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +DL121721,70A269,ALF,11/28/2012,"Resident #1 was administered a narcotic pain medication resulting in him/her not feeling well for two days. The facility failed to update Resident #1_x001A_s Medical Administration Record (MAR) showing PRN parameters for narcotic pain medication. The facility failed to provide a safe medication administration system. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DL121647,70A269,ALF,11/19/2012,"The facility failed to provide a safe medication administration system resulting in Resident #1 not timely receiving his/her pain medication and experiencing pain for an extended time. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DL133193,70A269,ALF,5/5/2013,"Resident #1 called 911 and was transported to the hospital and started on antibiotics and IV fluids. He/she was confused and had infection in his/her legs. Resident #1_x001A_s feet also had sores, were odorous, draining and the toenails were extremely long and curling. Staff were unaware of the current condition of Resident #1_x001A_s legs and feet. The facility failed to follow Resident #1_x001A_s service plan and adequately meet his/her care needs. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DL146229,70A269,ALF,2/17/2014,It was reported that Resident #1 was not receiving appropriate care. He/she was having incontinence issues associated with a UTI. No refusal of toileting care was documented. The facility failed to appropriately care plan for Resident #1 for a change of condition and train staff regarding refusal of care. The failures are a violation of Oregon Administrative Rules.,2,,,, +DL147497,70A269,ALF,6/23/2014,Resident #1 sold Resident #2 copied movies. Resident #1 purchased a tablet for Resident #3. There were discrepancies regarding the amount of money Resident #3 gave Resident #1. The facility failed to provide a safe environment for Resident #2 and Resident #3. The failure is a violation of Oregon Administrative Rules.,2,,,, +DL150115,70A269,ALF,2/2/2015,"Resident #1 was found on the floor of his/her bathroom at approximately 10:50 p.m. EMTs were called and Resident #1 was transported to the hospital at 4:33 a.m. Resident #1 sustained a hip fracture. Resident #1 remained on the floor for over three and one half hours before 911 was called. The facility failed to timely coordinate transportation to the hospital for Resident #1 and appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH117076,70A270,ALF,5/25/2011,"Resident #1 suffered a fall in his/her room at the Facility at approximately 8 P.M. When attempting to call for assistance, a cabinet fell on the resident_x001A_s hand. The resident_x001A_s service plan indicated that staff was to check on the resident twice per shift, however staff did not check on the resident until 10 A.M. the following morning, leaving the resident on the floor of his/her room in pain for an extended period of time.",3,300,,,Neglect +BH116950,70A270,ALF,4/23/2011,"When a resident of the Facility called upon staff for assistance he/she was yelled at by a Facility staff member. As a result of getting yelled at the resident wasn't able to ask for the assistance he/she needed, which was assistance with toileting.",2,0,,, +BH118568,70A270,ALF,11/11/2011,"On 11/11/11 at approximately 3am, Resident #1 awoke to someone entering his/her room and stole a plaque containing jewelry and some antique pocket watches. The facility's policy directed that exterior doors be locked; however Reported Perpetrator 2 (RP2) had left the facility exterior door unlocked on 11/11/11. Circumstances of the theft indicate that the items were stolen by someone familiar with Resident #1's apartment, most likely a staff member. An unknown individual was responsible for the theft of Resident #1's belongings. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +CO12019,70A270,ALF,1/19/2012,"The facility failed to timely refer a significant change of condition to the RN and failed to ensure the RN conducted an assessment. Resident #4 suffered severe weight loss, experienced pain and demonstrated symptoms of depression.",3,300,,,Neglect +BH129576A,70A270,ALF,3/5/2012,"Resident #1 was care planned for staff to provide toileting assistance four times per shift during waking hours, included peri-care; and had physician orders for a medication to be applied at two skin areas. Resident #1 was found to have skin breakdown and irritation at the two skin area sites. The facility failed to follow the care plan and failed to follow physician orders. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH129576B,70A270,ALF,3/5/2012,"Resident #1 had physician's orders to administer a PRN rescue inhaler to assist with breathing. Resident #1 was noted to be visibly weak and short of breath for a few days; however the PRN rescue inhaler was not administered. The facility failed to follow physician's orders resulting in unreasonable discomfort for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH129867,70A270,ALF,1/7/2012,"Resident #1 had physician orders for a routine narcotic pain medication as well as a narcotic pain medication as needed for pain. On 1/7/12, he/she experienced pain and used his/her call light; however it took at least 1.5 hours before his/her pain medication was delivered. The facility failed to administer ordered medication as requested by Resident #1 resulting in continued pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH120305,70A270,ALF,6/11/2012,"The facility failed to adequately care plan and failed to implement interventions related to Resident #1's multiple falls with injuries. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +BH118384,70A270,ALF,11/4/2011,"Resident #1's care plan required four checks per shift and required his/her cat's litter box be cleaned daily. On 11/4/11, there was dried feces on his/her carpet and in the bathroom; and the litter box appeared not to have been changed in days. The facility failed to provide a safe and homelike environment and failed to follow the care plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH132789,70A270,ALF,3/29/2013,"Resident #1 left the facility, fell and fractured a hip before facility staff found him/her in the parking lot. The exit door Resident #1 used reportedly had a doorbell-type alarm that sounded in the reception area when the door was opened. Staff stated they did not hear the alarm. The facility failed to provide a safe environment. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH133861,70A270,ALF,7/6/2013,"Reported Perpetrator 2 (RP2) and Witness 2 provided care to Resident #1 when he/she was resistant and aggressive. Resident #1's service plan stated when Resident #1 was aggressive, staff should leave and re-approach later. RP2's and Witness 2's statements were conflicting regarding what happened. Witness 2 stated RP2 slapped Resident #1 on the arm. RP2 stated he/she did not strike Resident #1. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +BH134791,70A270,ALF,10/13/2013,"In October 2013, Resident #1, #2, and #3 had money stolen out of their rooms. An unknown individual was found to be responsible for the thefts, which is considered financial exploitation. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +BH134720,70A270,ALF,12/20/2012,"In December 2012 the facility failed to provide a safe environment In relation to theft of Resident #1's property, and is a violation of Oregon Administrative Rules. The failure is a violation of resident rights, is considered theft of resident property by an unknown individual, and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BH134997,70A270,ALF,10/7/2013,"The Facility failed to appropriately care plan for falls for Resident #1 over a period of time resulting in several injuries on his/her body. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO14071,70A270,ALF,3/20/2014,"The Facility failed to evaluate and monitor, and failed to ensure a Registered Nurse (RN) assessed and documented findings for Resident #6 who experienced a significant change of condition related to weight loss. Resident #6 experienced severe weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH145800,70A270,ALF,12/4/2013,"The facility failed to follow a physician's order to collect a lab sample from Resident #1. The physician was waiting on the lab results before prescribing additional medication, and Resident #1`s infection and pain worsened. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BH148847,70A270,ALF,6/15/2014,"On 6/23/14, Resident #1's physician approved to test for a UA and culture; however it wasn't done until 7/11/14. The lab results were positive for infection. The facility failed to assure timely medical treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH148566,70A270,ALF,9/12/2014,"On 9/3/14, Reported Perpetrator 2 (RP2) spoke loudly to Resident #1 to take his/her medications. Resident #1 was hard of hearing. On 9/12/14, RP2 assisted Resident #1 up-right in his/her wheelchair. Resident #1 noted pain in his/her shoulder; however the swelling and pain could relate to a pre-existing medical condition. Resident #1 was not treated with respect and dignity by RP2 who was noted to speak loudly, forcefully, or in a frustrating sounding tone to Resident #1. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.",2,,,, +BH150211,70A270,ALF,12/29/2014,"The facility failed to evaluate and monitor, and failed to ensure a Registered Nurse (RN) assessed and documented findings for Resident #1 who experienced weight loss. The facilities failures resulted in Resident #1's undesirable weight loss and transportation to the hospital for treatment on 12/29/14. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH149436,70A270,ALF,12/2/2014,"Resident #1 had approximately twelve (12) falls between 9/13/14 and 12/3/14. He/she sustained an injury from a fall on 11/30/14, requiring transportation to the hospital. The facility failed to appropriate care plan for Resident #1_x001A_s falls and failed to implement safety measures as assessed on 9/24/14. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH135423,70A270,ALF,3/10/2013,It was discovered that Resident #1 had missing narcotic medications. An unknown individual is responsible for the theft of narcotic medications which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication administration system and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BH147527,70A270,ALF,1/14/2014,"The facility failed to ensure staff were properly trained to use Resident #1's Hoyer lift resulting in an improper transfer and Resident #1suffering bruising. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +BH153573C,70A270,ALF,5/15/2014,"The facility failed to follow Resident #1's care plan to be assisted with incontinence every two hours. Resident #1 was found soaked with urine on 10/7/14 and 10/9/14. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH153524,70A270,ALF,1/10/2015,Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan regarding skin issue. Resident #1 suffered unreasonable discomfort. RP2's actions are considered neglect of care and constitutes abuse. The facility failed to ensure Resident #1's care plan was followed which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +BC105769,70A271,ALF,11/28/2010,Two residents with histories of verbal inappropriate behavior were observed yelling at eachother in the dining room. The facility failed to assure resident rights resulting in loss of dignity. The failure is a violation of OARs.,2,0,,, +BC105806,70A271,ALF,10/22/2010,"The facility failed to provide a safe environment resulting in the loss of jewelry from Resident #1's room. The facility also failed to provide a safe locking drawer in Resident #1's room. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +BC117059,70A271,ALF,4/19/2011,"RP2 was assigned to pass medications to residents on April 19, 2011. RP2 was overwhelmed and did not pass out medications to all residents during the morning or noon administration times. Facility administration did not oversee RP2's performance. The facility failed to provide a safe medication administration system resulting in the potential for harm to residents. There were no observable negative effects as the result of the missed medications.",2,0,,, +BC117031,70A271,ALF,5/1/2011,"Multiple residents reported missing items from their rooms. The facility failed to provide a safe environment resulting in the loss of residents' property. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,, +BC117321,70A271,ALF,6/21/2011,"On June 21, 2011, an intoxicated Resident #2 was observed yelling and sexually harassing residents including blocking Resident #1 from leaving. Resident #2 had a history of harassing residents while intoxicated, however no interventions were documented on the service plan. Resident #1 expressed fear of Resident #2. The facility failed to appropriately address Resident #2's behavior resulting in harm to residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC120102,70A271,ALF,4/23/2012,"Resident #1 had a history of sexually inappropriate behavior. On April 23, 2012, Resident #1 was observed touching Resident #2 in a sexually inappropriate way. Resident #1 had one prior incident of touching Resident #2 in a sexually inappropriate way on January 6, 2012. Resident #2 did not have the capacity to consent. The facility failed to appropriately care plan and monitor Resident #1. The failure is a violation of resident rights and is considered sexual abuse.",3,2500,,,Sexual abuse +BC121865,70A271,ALF,12/4/2012,"Resident #1 reported items missing from her/his room including approximately $60 in cash. Resident #2 also reported missing items, but was later found. The facility failed to provide a safe environment. An unknown individual was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BC133096,70A271,ALF,4/27/2013,"Resident #1 was experiencing extreme pain and told facility staff he/she wanted to go to the hospital. Staff did not call emergency transport, gave Resident #1 pain medication and asked him/her to wait to see if the medications would take affect. Resident #1 called the ambulance him/herself and was transported to the emergency room where he/she was diagnosed as having a heart attack. The facility failed to assure timely medical treatment. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC148911,70A271,ALF,10/12/2014,"Resident #1 reported that ten (10) narcotic tablets were missing from his/her medication bottle. The investigation determined an unknown individual was responsible for the theft of medication, which constitutes abuse. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH118815,70A272,ALF,12/15/2011,Resident #1 was given too many of his/her prescribed narcotic pills by RP3 as instructed by RP2. Resident #1 was transported to the hospital and received treatment for an overdose. PR2 is found responsible for abuse. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Neglect +BH129798,70A272,ALF,2/1/2012,"Resident #1 reported that Reported Perpetrator 2 (RP2) was rough in handling him/her when providing care. The investigation determined that RP2 was in a hurry and rushed Resident #1 while providing care. RP2 did not hurt Resident #1, but made him/her feel uncomfortable. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",1,0,,, +HB105837,70A273,ALF,12/10/2010,Reported Perpetrator 2 (RP2) borrowed money from Resident #2 and also had a ring presumably to be Resident #1's in his/her possession.,2,0,Not Substantiated,Substantiated,Financial abuse +HB145929,70A273,ALF,1/28/2014,"Residents #1, #2, and #3 were independent with ADLs, were prescribed pain medication, and managed their own pain medications between October-December, 2013. All three residents reported pain medications missing from their apartments. Reported Perpetrator 2 admitted to taking Resident #3's narcotic pain medication, which is considered theft and constitutes financial exploitation. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +HB150809,70A273,ALF,4/6/2015,"Reported Perpetrator 2 (RP2) administered another resident's medications to Resident #1 and caught his/her mistake. RP2 was in a hurry, didn't normally pass medications but would sometimes cover for another employee. Resident #1 went to the hospital for precaution, returned the same day and had no ill effects. The facility failed to ensure a safe medication administration system which violates Oregon Administrative Rules.",2,,,, +CO13034,70A274,ALF,1/31/2013,"The Facility failed to ensure Resident #3 was assessed by a Registered Nurse when he/she experienced a significant change of condition and failed to monitor him/her. Resident #3 experienced a severe weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL132487,70A274,ALF,11/12/2012,"The Facility failed to properly evaluate Resident #1_x001A_s condition related to his/her slurred words (speech) and failed to service plan appropriately providing clear direction to staff regarding the delivery of services. Resident #1 was refused a two person transfer for toileting due to his/her slurred words. Resident #1 self transferred to the toilet, fell to the floor and fractured his/her right leg. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL133149,70A274,ALF,2/1/2013,"Resident #1's Care Plan stated he/she needed a two person assist with transferring. Reported Perpetrator 2 (RP2) transferred Resident #1 alone, resulting in significant injury to Resident #1's legs. The facility failed to ensure the Care Plan was implemented correctly. The failure is a violation of Oregon Administrative Rules. RP2 failed to follow the Care Plan. The failure is considered neglect and RP2 is responsible for abuse.",3,0,Not Substantiated,Substantiated,Neglect +AL150322,70A274,ALF,6/5/2014,"Resident #1 used a wheelchair for mobility. While Resident #1 was on the van lift, his/her wheelchair rolled down the hill and he/she fell onto the ground. The facility failed to ensure the facility_x001A_s van mechanical lift equipment was safely operating and failed to implement safety measures using the manual mode during mechanical lift failure to ensure resident safety. Resident #1 was transported to the hospital and diagnosed with a broken elbow. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL164478,70A274,ALF,1/21/2016,The facility staff failed to follow facility policies when Resident #1 violated the facility smoking policy. Resident #1's rights were violated. The facility failure is in violation of Oregon Administrative Rules.,2,,,, +MV164592,70A274,ALF,2/8/2016,"Resident #1 was left soiled for an unreasonable amount of time resulting in incontinence and unreasonable discomfort. The facility failed to ensure staff persons provided timely toileting assistance. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AS116078,70A275,ALF,12/30/2010,The facility failed to ensure Resident #1's Service Plan was followed as directed. RP2 provided assistance with bathing when care plan directed only stand by assist. Resident #1 reported the incident approximately a week later with no observable harm. The failure is a violation of OARs.,2,0,,, +AS118719,70A275,ALF,12/7/2011,Resident #1 reported missing an I-Pod from her/his room. An internal investigation was conducted and local law enforcement was notified. RP2 was suspected of the theft and later admitted to taking the I-Pod from Resident #1's room. The facility failed to ensure a safe environment. RP2 was substantiated for financial exploitation.,2,0,Not Substantiated,Substantiated,Financial abuse +AS120553,70A275,ALF,7/14/2012,RP2 did not normally work as a medication aide but was filling in and administered Resident #1 a pain medication at 5PM and another one at 8PM. Physicians' orders did not have scheduled pain medication for 5PM. The facilty failed to administer medication as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AS133588,70A275,ALF,6/18/2013,"Resident #1 reported $60 missing from her/his locked room. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown person was held reponsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +AS147981,70A275,ALF,7/18/2014,"Reported Perpetrator 2 (RP2) used Resident #1's debit card for his/her own use from May 4th through July 15th 2014. RP2 is responsible for theft, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1 from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB116808,70A276,ALF,4/19/2011,"The facility failed to follow Resident #1_x001A_s Service Plan resulting in being transported to the hospital for treatment. The failure is violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB120312,70A276,ALF,6/16/2012,The facility failed to appropriately evaluate and monitor Resident #1 after she/he experienced two falls during the same day. Resident #1 experienced a third fall before being transported to the hospital for an evaluation. There were no known significant injuries as a result of the falls. The failures are violations of Oregon Administrative Rules.,2,0,,, +HB133274,70A276,ALF,5/20/2013,Reported Perpetrator 2 (RP2) yelled at Resident #1 when he/she questioned what medications were being administered to Resident #1 and then RP2 threw the medication cup at Resident #1. The facility failed to protect Resident#1 from verbal and emotional abuse. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for verbal and emotional abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HB134928,70A276,ALF,11/4/2013,Reported Perpetrator #2 took a picture of Resident #1 and Resident #2 after Resident #1 wandered into Resident #2's room. The facility failed to protect Resident #1 and Resident #2 from having their picture taken without their knowledge or permission. This failure is a violation of Oregon Administrative Rules.,1,,,, +HB135336,70A276,ALF,12/10/2013,"Reported Perpetrator 2 (RP2) and Reported Perpetrator 4 (RP4) both accepted money from Resident #1. RP2 was responsible for taking $5440 and RP4 was responsible for taking $17,000. Taking this money is financial exploitation and constitutes abuse. The facility failed to protect Resident #1 from financial exploitation which is considered neglect and constitutes abuse.",4,300,Substantiated,Substantiated,Financial abuse +HB147255,70A276,ALF,5/30/2014,"On or about May 30, 2014, Resident #1 engaged in a physical altercation with Resident #2. The facility updated the resident's care plans to address behaviors. On June 3, 2014, Resident #3 wandered enter Resident #1's room after hearing an argument between Resident #1 and Resident #2. Resident #1 hit Resident #3 when she/he would not leave. The facility failed to follow Resident #1's care plan resulting in negative behavior affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB147477,70A276,ALF,6/20/2014,"Complainant reported three residents narcotic medications were discovered switched with non-narcotic medications. Appropriate parties were notified and an internal investigation revealed RP2 was the staff person who had access during the time that the thefts took place. Drug testing was conducted on staff and RP2's results came back positive for opiates. RP2 was found responsible for theft of narcotics, is considered financial exploitation and constitutes abuse. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB150057,70A276,ALF,1/27/2015,"The facility failed to adequately monitor after Resident #1 experienced a change of condition that resulted in transportation to the hospital for treatment. The facility also failed to provide appropriate documentation to the dentist, and failed to receive and follow direction from the dentist after the extraction of multiple teeth. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +OR0000996100,70A276,ALF,8/21/2015,,1,,,Substantiated, +OR0000996101,70A276,ALF,8/21/2015,,1,,,Substantiated, +DA105941,70A277,ALF,11/8/2010,The facility failed to provide a safe environment resulting in the loss of money from Resident #1's wallet.,2,0,Not Substantiated,Substantiated,Financial abuse +DA117143,70A277,ALF,5/22/2011,"The Facility failed to provide clear direction for staff conducting alert status checks thus, not providing a safe environment. Resident #1 fell in his/her room and was discovered hours later suffering a fractured hip. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",0,300,,,Neglect +DA117499,70A277,ALF,7/18/2011,The facility failed to provide a safe environment resulting in a loss of $100 and three chains missing from Resident #1's locked drawer. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +DA118307,70A277,ALF,10/20/2011,"Resident #1 reported money missing from the locked drawer in his/her apartment. An unknown individual is responsible for the theft of money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules. + + + +The Letter of Determination was completed at a later date due to the extended period of time between the incident date and processing by the Department.",2,0,Not Substantiated,Substantiated,Financial abuse +DA129071,70A277,ALF,1/20/2012,Reported Perpetrator 2 (RP2) used profane language regarding the condition of Resident #1's bathroom within his/her hearing distance. RP2's statements were upsetting to Resident #1. RP2's actions meet the definition of verbal or emotional abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +DA128996,70A277,ALF,1/12/2012,"Resident #1 reported approximately $330 missing from his/her locked drawer, which occurred between 12/29/11-1/12/12. The investigation revealed that the locked drawer had been tampered with. The facility failed to provide a safe environment, resulting in Resident #1's loss of money. An unknown individual is responsible for the theft of money.",3,0,Not Substantiated,Substantiated,Financial abuse +DA129373,70A277,ALF,2/28/2012,"Resident #1 had over $200 in his/her bag in February, 2012. On 2/28/12, he/she reported that the $200 was missing from his/her bag that was kept in his/her apartment. The facility failed to provide a safe environment, resulting in Resident #1's loss of money, which violates Oregon Administrative Rules. An unknown individual is responsible for the theft of money.",3,0,,,Financial abuse +DA129421,70A277,ALF,2/1/2012,"Upon returning from an outside stay for medical treatment, Resident #1 was not appropriately care planned regarding his/her change in toileting needs and was not monitored as the ""alert status"" directed. Resident #1 was found in an immobile position the morning of 2/20/12 saturated in urine wearing the same clothes as the previous day. The facility failed to provide care and services to Resident #1, and failed to conduct and internal investigation. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +DA129686,70A277,ALF,3/23/2012,"The facility failed to provide a safe environment resulting in a loss of approximately $1,260 from Resident #1_x001A_s locked box and coins from a jar. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse.",3,350,,,Financial abuse +MV135244C,70A277,ALF,11/21/2013,According to Resident #3's care plan he/she is care planned for a 2 person transfer. An investigation determined facility staff have not followed the care plan and have transferred Resident #3 with the assistance of only 1 person. This failure to follow the care plan is a violation of Oregon Administrative Rules.,2,,,, +DA147001,70A277,ALF,4/24/2014,"The facility failed to ensure Reported Perpetrator 2 (RP2) conducted an RN assessment for Resident #1_x001A_s change of condition. Resident #1 suffered swollen legs that wept fluid. The facility also failed to provide a safe medication administration system to ensure Resident #1_x001A_s medications were available to administer as ordered. Resident #1 went without needed medications. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. RP2_x001A_s actions are considered neglect and constitute abuse.",3,300,Substantiated,Substantiated,Neglect +DA147034,70A277,ALF,5/5/2014,"On or about 5/5/14, Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) failed to administer a narcotic medication appropriately, as ordered, to Resident #1. Resident #1 was administered 3 times the dose on two consecutive administrations. He/she suffered drowsiness throughout the day. RP2's and RP3's actions are considered neglect of care which constitutes abuse. The facility failed to ensure a safe medication administration system and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +DA147069A,70A277,ALF,5/14/2014,It was discovered that Resident #1 had multiple patches on his/her body that appeared to have been on for an extended period of time. He/she was scheduled to wear a new patch daily and every 24 hours have it removed and apply a new one. The facility failed to ensure his/her orders were followed resulting in an unsafe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +DA147069B,70A277,ALF,5/14/2014,"Resident #1's service plan indicated that he/she sometimes refused to shower or be changed and cleaned. He/she was found dirty, mal-odorous and had feces between his/her toes and around peri-area. The facility failed to provide service to ensure proper hygiene. The failures are a violation of resident rights and dignity and Oregon Administrative Rules.",2,,,, +MV152193A,70A277,ALF,5/29/2015,"Reported Perpetrator 2 (RP2) financially exploited seven residents totaling over $9,000 combined, over the course of three months. RP2's actions are considered financial exploitation which constitutes abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",4,,Not Substantiated,Substantiated,Financial abuse +MV152193B,70A277,ALF,5/29/2015,"In May, 2015 Resident #1 reported money missing from his/her room. The facility failed to provide a safe environment to ensure safety of resident's money. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC116280,70A278,ALF,1/11/2011,"The Facility failed to adequately assess and intervene when Resident #1 experienced a change in his/her condition. The resident did not receive appropriate care and services, resulting in his/her condition declining and being sent to the hospital for treatment. Upon arriving at the hospital the resident was found to be severely dehydrated and experiencing kidney failure.",3,300,,,Neglect +BC118291,70A278,ALF,10/7/2011,Resident #1 and Resident #3 were missing narcotic pills. Resident #2 did not receive a pain medication as documented. Reported Perpetrator 2 failed to complete an incident report or notify the facility administrator. The theft of narcotic medications resulted from actions of an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +BC118266,70A278,ALF,10/4/2011,"Resident #1 did not receive dosages of PRN pain medication from 9/6/11 to 9/8/11 because the facility did not reorder timely. On 9/16/11, Resident #1's physician changed the dosage of a medication and he/she was not administered the correct dosage until 9/20/11.",2,0,,, +BC129125,70A278,ALF,1/12/2012,"Resident #1 had acute respiratory problems and spray chemical cleaning agents exacerbated his/her condition. Resident #1 had already had one adverse reaction and his/her care plan was not updated. These types of chemicals were used in his/her room again, contributing to Resident #1 being taken to the doctor and ultimately admitted to the hospital. The facility failed to make appropriate updates to Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC121517,70A278,ALF,9/28/2012,Resident #1 reported jewelry missing from his/her apartment. An unknown individual was responsible for the loss of property. The facility failed to provide a safe environment and to report and investigate the incident. The failures are a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC133850,70A278,ALF,7/4/2013,It was reported that Resident #1 was missing keys to his/her mailbox and lock box. $200.00 was missing from his/her lock box. An unknown individual was determined to be responsible for the loss of Resident #1_x001A_s money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BC133962,70A278,ALF,7/28/2013,Resident #1 was prescribed medication to be administered once per day. Resident #1 did not receive the ordered medication on two occasions. The facility failed to administer Resident #1_x001A_s medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC134863,70A278,ALF,10/25/2013,Resident #1 grabbed Resident #2_x001A_s arm in an aggressive manner. Resident #1 has thrown things at another resident and was verbally aggressive toward other residents. Resident #1 has also threatened harm to other residents before this incident. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC145903,70A278,ALF,12/24/2013,Resident #1 reported gift cards and cash missing from his/her room. An unknown individual was responsible for the loss for theft which constitutes financial exploitation. Resident #1 did receive a $100 credit on the next month's rent from the facility. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BC135416,70A278,ALF,11/19/2013,"A check from Resident #1's bank account was made out to a hospital in the amount of $100.00, then altered and made out to Portland Spirit in the amount of $403.50. Resident #1 denied ever writing a check to Portland Spirit. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +BC146303,70A278,ALF,3/5/2014,Resident #1 was administered two medications together that had different administration times. He/she was sent to the hospital as a precaution. He/she had no adverse effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC146522,70A278,ALF,2/25/2014,Resident #1 fell in his/her room. He/she paged for help. Care givers were busy with other residents. Resident #1 did not receive assistance in a timely manner. The facility failed to timely respond to Resident #1's call for assistance. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC148755,70A278,ALF,6/23/2014,"Resident #1's medication was discovered as discontinued in error when staff conducted a medication review after the resident experienced a change of condition. The facility failed to ensure a safe medication administration system resulting in harm to Resident #1. The failures are violations of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +BC149692,70A278,ALF,11/17/2014,"Resident #1 reported missing diamond earrings. Her/his lockbox was also observed to be tampered with. Resident #1's cognition was intact and always locked her/his door when not in the room. The facility failed to conduct an investigation or implement changes to address the theft and prevent future similar incidents. The failures are violations of resident rights, are considered neglect of care and constitute abuse. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Substantiated,Substantiated,Financial abuse +BC151360,70A278,ALF,3/15/2015,"Resident #1 reported RP2 borrowed over $1,000 from the resident and never paid her/him back after quiting. The facility failed to ensure a safe environment and is responsible for the conduct of its' staff. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BC151768,70A278,ALF,6/27/2015,RP2 used physical force in attempting to get Resident #1 to do something she did not want to resulting in bruising and a skin tear to the residents arms. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment and ensure Resident #1 was treated with respect and dignity. The failures are violations of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BC153106,70A278,ALF,9/10/2015,"Three residents had missing money and bank cards from their respective rooms. An investigation was initiated and law enforcement notified. Several charges were made to two of the residents' bank cards. Law enforcement investigation revealed RP2 was connected to the thefts. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +CO16092,70A278,ALF,2/2/2016,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the re-licensure survey findings completed on February 2, 2016 (JDVB11).",3,,,,Neglect +TM118639,70A279,ALF,11/28/2011,"Resident #1 was incontinent of bowel and bladder, staff to provide peri-care, and had experienced skin breakdown the month of October 2011. Between 11/2/11 and 11/25/11 there was no documentation regarding skin checks. On 11/25/11, he/she was discovered to have two large pressure ulcers. The facility failed to adequately care plan and monitor Resident #1's skin resulting in two pressure ulcers developed on his/her buttocks. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +TM128918,70A279,ALF,1/10/2012,Resident #1 prepared for his/her bathing assistance and placed his/her alert necklace on the dresser; however staff didn't come so he/she went to bed. Resident #1 was found on the floor with noted abrasions to his/her legs. The alert necklace was still on the dresser. The facility failed to follow Resident #1's scheduled bathing assistance. The failure is a violation of Oregon Administrative Rules.,2,0,,,Neglect +TM103918,70A279,ALF,3/22/2010,The facility failed to properly care plan for Resident #1's known fall risk. The failure is a violation of Oregon Administrative Rules.,2,0,,, +TM104294,70A279,ALF,5/13/2010,The facility failed to visually observe Resident #1 take his/her ordered medication. Approximately 18 pills were discovered on his/her nightstand. The failure is a violation of Oregon Administrative Rules.,2,0,,, +TM104272A,70A279,ALF,5/4/2010,The facility failed to provide a safe environment and failed to properly plan care for Resident's #1's wandering issues. The failures are a violation of Oregon Administrative Rules.,2,0,,, +TM104272B,70A279,ALF,5/4/2010,The facility failed to follow Resident #1's service plan for toileting and bathing resulting in adequate hygiene. The failure is a violation of Oregon Administrative Rules.,2,0,,, +TM105147,70A279,ALF,7/18/2010,The facility failed to have Resident #1's medication available resulting in him/her being without medication for approximately 13 days. The failure is a violation of Oregon Administration Rules.,2,0,,, +TM105148,70A279,ALF,8/26/2010,"Resident #1 was care planned for bathing twice a week and was noted to refuse bathing due to fear of water from personal past. Staff were to report refusals to the facility RN and RCC. On 8/26/10, he/she refused bathing. Reported Perpetrator 2 (RP2) proceeded to bath Resident #1 and he/she was resistant, upset and angry throughout RP2 bathing him/her. The facility failed to follow the care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +TM105283B,70A279,ALF,9/10/2010,"On 9/10/10, Resident #1 was discharged from the hospital with orders for a new medication; however proper protocol was not followed to order the medication. Resident #1 did not get his/her new medication until 9/13/10. There were no ill effects observed. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,,Neglect +TM105940,70A279,ALF,11/4/2010,The facility failed to provide Resident #1 a consistently working pendent necklace and call system; failed to document when 1/2 hour checks were/were not performed; and failed to document a change of condition. The failures are a violation of Oregon Administrative Rules.,2,0,,, +CO13027,70A279,ALF,2/21/2013,"The Facility failed to evaluate and monitor, and ensure an RN assessment with documented findings for Resident #5 who experienced a significant change of condition. Resident #5 lost a severe amount of weight. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +TM132450,70A279,ALF,2/5/2013,"The Facility failed to appropriately manage and handle personal incidental funds (PIF) for Resident #1, Resident #2, Resident #3 and Resident #4. The failure resulted in the loss of PIF monies for the four residents. The failures are a violation of resident rights, are considered financial exploitation and constitute abuse.",3,300,,,Financial abuse +TM132793,70A279,ALF,3/19/2013,"It was reported that Reported Perpetrator 2 (RP2) was physically rough with Resident #1. The facility failed to protect Resident #1 from rough treatment. The failure is a violation of Oregon Administrative Rules. RP2 handled Resident #1 roughly, which constitutes abuse. RP2 is responsible for abuse.",2,0,Not Substantiated,Substantiated,Physical Abuse +TM120481,70A279,ALF,7/6/2012,"On 07/09/12, some of Resident #1's medications were found in Reported Perpetrator 2's (RP2) apron pocket. Resident #1 was scheduled to go on an outing on 07/01/12 and the medications found were intended for that outing, which Resident #1 did not go on. Resident #1's Medical Administration Record indicated he/she did not take the medications on 07/01/12 but there was no explanation as to why. RP2 stated Resident #1 declined his/her medications on 07/01/12 and RP2 placed the medications in the apron pocket and forgot about them. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +CO14109,70A279,ALF,4/24/2014,"The facility failed to ensure timely RN assessment for significant changes of conditions. Resident #4 experienced skin breakdown and weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,,Neglect +TM147384,70A279,ALF,6/11/2014,Witness #1's facility keys were left unsecured for approximately 3 hours on 6/11/14. Funds were discovered missing from the facility lockbox belonging to Resident #1 and Resident #2. The facility reimbursed the funds. The facility failed to take reasonable precautions to provide a safe environment and the violate Oregon Administrative Rules.,2,,,, +TM149081,70A279,ALF,10/14/2014,"Reported Perpetrator 2 (RP2) was found responsible for misappropriating Resident #1's, Resident #2's, and Resident #3's PRN pain medication. RP2's actions are considered financial exploitation, which constitutes abuse. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +TM150358,70A279,ALF,2/12/2015,Resident #1's pain medication went missing from his/her room. The investigation determined an unknown person is found responsible for the theft of medication. The facility failed to provide a safe environment and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +TM150534,70A279,ALF,2/15/2015,"The facility failed to ensure an appropriate assessment of Resident #1's injuries after his/her fall. The failure resulted in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +TM151184,70A279,ALF,2/6/2015,Resident #1's ring went missing. A search was conducted but the ring was not found. The investigation determined an unknown person is found responsible for the theft of Resident #1's ring. The facility failed to provide a safe environment and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +TM151186,70A279,ALF,4/29/2015,"Resident #1 reported money that went missing. An investigation revealed there was no specific evidence to indicate who might have taken the money. The facility failed to take reasonable precautions to protect residents from theft of money. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation which constitutes abuse.",2,300,,,Financial abuse +TM151187,70A279,ALF,4/21/2015,Resident #1 discovered cash money missing from his/her room. The investigation determined an unknown individual is found responsible for the theft of his/her money. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +TM151340,70A279,ALF,4/21/2015,"The facility failed to provide a safe medication administration system to ensure Resident #1 received his/her necessary arthritis medication. Resident #1 did not receive his/her medication as ordered. The facilities failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +OR0001017200,70A279,ALF,10/19/2015,,0,,,Substantiated, +AL132346,70A280,ALF,4/20/2011,"The facility failed to seek timely medical treatment for Resident #1 who had expressed complaints of not feeling well beginning 4/20/11. Resident #1 was hospitalized on 4/28/11 with a severe case of infectious, intestinal disease, urinary tract infection and was given intravenous fluids. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +A civil penalty was not issued to the extended period of time between the incident date and processing by the Department.",3,0,,,Neglect +CO15110,70A280,ALF,6/5/2015,"Resident #1 lost 16 pounds or 14.8% of her/his body weight between March 8 and April 29, 2015. The facility failed to evaluate, document, monitor and develop appropriate interventions after Resident #1 experienced a significant change of condition. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AL151952,70A280,ALF,3/6/2015,RV1's service plan indicated that he/she was a two person transfer but five separate witnesses and facility chart notes indicated that RV1 was a three or four person transfer. RV1 suffered four separate injuries to his/her lower extremities from January 2015 to March 2015. On more than one occasion RV1 sustained injuries while facility staff were transferring RV1 to and from his/her wheelchair. The facility's failure to assist with safe transfers is considered neglect of care and constitutes abuse.,2,,,,Neglect +AL153093,70A280,ALF,10/8/2015,"On or about October 8, 2015, the facility discovered missing pain medication for Resident #1 and Resident #2. The medication was taken by an unknown individual and this person is responsible for theft of medication, which is considered financial exploitation and constitutes abuse. This failure is a violation of the Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +AL116045,70A281,ALF,9/25/2010,"Resident #1 had money in his/her wallet that was kept in a bag in his/her apartment. Two days after putting money in his/her wallet, the money was missing. He/she had a locking drawer in the apartment but didn't use it. The facility re-keyed the lock on his/her locking drawer and reimbursed him/her the full amount. After this incident, Resident #1 will use the locking drawer for all valuables and keep his/her apartment door locked.",2,0,,, +AL116513,70A281,ALF,10/27/2010,"The Facility failed to provide a safe environment to protect residents from theft of money when known thefts were occurring. Resident #1 and Resident #2 discovered money missing from their apartments. The Facility_x001A_s failures are a violation of resident rights, are considered financial exploitation and constitute abuse.",3,300,Substantiated,Substantiated,Financial abuse +AL120368,70A281,ALF,3/7/2012,"Resident #1 had a predictable mealtime routine, documented by the dining room meal roster and known by staff and other residents. Resident #1 went unnoticed for at least 24 hours. He/she was found in his/her apartment on the floor of his/her shower stall with the water running and he/she was transported to the hospital. The facility failed to provide a safe environment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO13045,70A281,ALF,3/27/2013,"The Facility failed to update Resident #1_x001A_s service plan to reflect his/her current needs and failed to evaluate, monitor, and provide an RN assessment for his/her significant change of condition. Resident #5 experienced a worsening pressure ulcer. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL134909,70A281,ALF,6/25/2013,"Several medications were taken from the medication room between 8/15/13 - 9/01/13 belonging to and intended for four residents, and cash had been taken from six individual residents beginning 6/25/13. Residents and/or resident family members made complaints to facility staff regarding the missing money; however the facility did not immediately notify the local APD/AAA office nor law enforcement. The facility failed to immediately report suspected abuse, failed to conduct an internal investigation, and failed to provide a safe medication administration system. The facility failed to protect residents from theft of money and theft of medications. The failures are a violation of resident rights, are considered neglect of care resulting in financial exploitation and constitute abuse. Reported Perpetrator 2 (RP2) had been identified and admitted to the theft of medications and cash money. RP2 is found responsible for theft, constituting abuse. + + + +This incident warranted a civil penalty; however one will not be issued due to the change of ownership effective 02/01/14.",3,,Substantiated,Substantiated,Financial abuse +AL135112,70A281,ALF,11/18/2013,Resident #1 was care planned with an allergy to shellfish. He/she was served a meal from the kitchen that contained shrimp; however he/she noticed the shrimp and did not eat it. The facility failed to follow his/her care plan and the failure is a violation of Oregon Administrative Rules.,2,,,, +AL147054,70A281,ALF,11/26/2013,Reported Perpetrator 2 (RP2) became frustrated with Resident #1 and yelled at him/her to stop dragging his/her feet as RP2 was pushing Resident #1 in the wheelchair. RP2 failed to treat Resident #1 with dignity and respect. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,,,, +AL151902,70A281,ALF,9/22/2014,"Resident #2 pushed Resident #1 causing him/her to fall to the floor resulting in a rug burn and bruise. Resident #1 was known to have been ""picking on"" Resident #2 prior to this incident. The facility failed to implement interventions and care plan appropriately regarding behaviors. The failures are a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +BH135370,70A284,ALF,11/26/2013,"Resident #1 was administered incorrect medications for two weeks resulting hospitalization. Medication orders for another resident were mixed into Resident #1's medication orders. Resident #1 was administered medications prescribed for another resident. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +WB116095,70A285,ALF,1/4/2011,"The facility ran out of Residents #1's regular medication, resulting break-through pain medication only for approximately three days. He/she suffered withdrawal symptoms.",2,0,,,Neglect +WB104398,70A285,ALF,5/14/2010,"Resident #1 and Resident #2 required medical testing four times per day which would determine medication administration. The results recorded by Reported Perpetrator 2 were inconsistent with the digital tester and indicated Resident #1 and Resident #2 should have been administered medication. Between April 1-15, 2010, Resident #1 was not administered required medication approximately 19 times and Resident #2 approximately 8 times. The facility failed to maintain a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +WB129274,70A285,ALF,1/21/2012,Reported Perpetrator 2 spoke inappropriately to Resident #1. The facility failed to assure resident rights and the failure is a violation of Oregon Administrative Rules.,2,0,,, +WB129900,70A285,ALF,4/19/2012,"On 4/18/12, Resident #1 reported $350 was missing from his/her room. A search was conducted of his/her room and found nothing. An unknown individual is responsible for the loss of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +WB120393,70A285,ALF,6/23/2012,"On 6/20/12, Resident #1 cashed a check for $600 and then discovered it missing on 6/23/12. An unknown person is responsible for the theft of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +MV129607,70A285,ALF,3/23/2012,Resident #1 discovered a significant amount of money missing from his/her wall safe. He/she had the only existing key to the safe and kept it in his/her trouser pocket. An unknown person is responsible for the theft of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +BH120008,70A286,ALF,4/1/2012,"Resident #1 was diagnosed with a medical condition that required regularly scheduled medication and monitoring. On or about May 3, 2012 Resident #1 complained about her/his leg hurting and was observed with a bruise. The bruise was noted to go up the thigh and Resident #1 was transported to the hospital for treatment on May 6, 2012. Facility documentation revealed Resident #1 received the wrong dosage of medication from November 18, 2011 through April 29, 2012. The facility failed to provide a safe medication administration system resulting in the potential for serious harm to Resident #1.",3,300,,,Neglect +BH121473A,70A286,ALF,10/16/2012,The facility failed to ensure Resident #1 received her/his medication as ordered resulting in the potential for harm. Staff documented that Resident #1 received her/his medication when she/he was out of the facility and they did not provide them. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ST117758,70A287,ALF,8/15/2011,"The facility failed to assess and intervene when Resident #1 experienced a change of condition. Resident #1 was transported to the hospital for treatment. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST128960,70A287,ALF,1/16/2012,"Resident #1 hit Resident #2 in the head and face with a spoon multiple times. Resident #1 had a documented history of unpredictable behaviors and aggression. The facility failed to monitor and address Resident #1_x001A_s behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST129505,70A287,ALF,3/15/2012,"Resident #1 was provided appropriate and adequate care when he/she was in significant pain and exhibited other symptoms. + + + +Resident #2 eloped from the facility and fell sustaining injuries. The facility failed to assure Resident #1 was safe, as he/she was a known elopement risk. The failure is a violation of Oregon Administrative Rules.",1,0,,, +ST133687,70A287,ALF,6/7/2013,Resident #2 is known to demand money and items from other residents. This behavior makes other residents feel bad and uncomfortable. Residents also feel forced to give Resident #2 money to make things easier. The facility failed to address Resident #2's behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +ST146594,70A287,ALF,4/2/2014,Resident #1 reported money missing from his/her room on two separate occasions. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The facility also failed to conduct an investigation. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ST147699,70A287,ALF,7/10/2014,"Resident #1 required full assistance from facility staff. Resident #1_x001A_s service plan stated he/she was a two person assist for all transfers and was to be escorted to meals and activities. Resident #1 was to be turned every two hours, however, the schedule was not followed. Resident #1 developed two areas of skin breakdown. Resident #1 was also unable to feed him/herself and had to wait until staff had time. The facility failed to follow Resident #1_x001A_s service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST148524,70A287,ALF,6/28/2014,"Resident #1 had a history of falls. He/she fell in his/her room and waited for assistance. Resident #1 was able to get to his/her phone and called a family member who came to the facility to assist Resident #1 off the floor. Until the family member alerted staff they were unaware that Resident #1 had fallen. The facility failed to follow Resident #1's care plan regarding safety checks by staff and failed to appropriately update Resident #1's care plan to address fall interventions. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ST150041,70A287,ALF,1/26/2015,"Resident #1 went to a physician's appointment and it was discovered that he/she had an infection in his/her lower extremity. Staff was unaware that he/she had the infection. The facility failed to follow Resident #1's care plan regarding routine skin checks, bathing and foot care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST150236,70A287,ALF,1/13/2015,"Resident #1 was a known fall risk. He/she had several falls while at the facility. Resident #1's fall on January 12, 2015, resulted in him/her being transported to the hospital. He/she sustained broken ribs. The facility failed to adequately update Resident #1's care plan to address fall interventions. The facility also failed to provide adequate staffing. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ST152484,70A287,ALF,8/13/2015,The facility was responsible for caring for Resident #1's device that assists with urination. Peri care was not being done properly by staff. The facility failed to provide appropriate care to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +ST152567,70A287,ALF,8/24/2015,"Resident #1 had eleven falls during a three month period, with no amendments to his/her care plan. Resident #1 sustained injuries from the falls. The facility failed to appropriately update Resident #1's care plan regarding fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST152908,70A287,ALF,9/22/2015,Resident #1 had a wound on his/her right foot that required daily bandage changes. The bandage was to be changed on a daily basis per Resident #1's physician's order. Resident #1's bandage was not being changed according to the physician's order. The facility failed to follow a physician's order. The failure is a violation of Oregon Administrative Rules.,2,,,, +ST153851,70A287,ALF,10/13/2015,"Resident #1's care plan stated he/she required complete assistance with showering/bathing needs and he/she was scheduled to be bathed twice per week. Resident #1 received four showers in September and one shower during the first fifteen days of October. It was also observed that Resident #1's room had a strong malodor, the bed linens were visibly stained and soiled and the floor had crumbs and stains. The facility failed to follow Resident #1's care plan and provide service. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ST153728,70A287,ALF,11/24/2015,"The facility failed to provide a safe medication administration system. On November 11, 2015 during a narcotic medication review it was discovered that staff were not recording the dispensing of medications in the electronic Medication Administration Record. There was no negative outcome to residents. The failure is a violation of Oregon Administrative Rules.",2,,,, +ST153897,70A287,ALF,10/13/2015,"Resident #1 had a medical procedure done that required the facility to provide ongoing care for his/her wound. Resident #1 complained of pain and at a follow up visit with his/her physician, concerns were raised that the wound was not properly cared for. The facility failed to provide appropriate care for Resident #1's wound. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST164458,70A287,ALF,2/1/2016,"On January 26, 2016, Resident #1 fell in his/her room. Resident #1 reported pain and requested transport to the hospital. Facility staff did not call 911 or schedule Resident #1 for an assessment as stated in his/her care plan. Resident #1 called 911 him/herself and was transported to the hospital. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ST164468,70A287,ALF,2/1/2016,"Resident #1 was sent to the hospital for evaluation of his/her foot infection/pain and returned to the facility with valid prescriptions. Resident #1 did not receive the medications for several days after being discharged from the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO11112,70A288,ALF,8/31/2011,"The facility failed to assess and monitor Resident #7_x001A_s significant change of condition resulting in medical condition worsening. Resident #7 was observed with a stage 3 pressure ulcer on her/his right great toe 12 days after the open wound was found. The failures are violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC120338,70A288,ALF,5/13/2012,"Resident #1 reported 12, $1.00 gold coins missing from her/his room. An internal investigation was unable to produce suspects and the resident was reimbursed. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for financial exploitation and is considered abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BC132090,70A288,ALF,1/5/2013,Resident #1 reported $117.00 missing from his/her apartment. He/she locks their room door when leaving. An Unknown individual was responsible for the loss of Resident #1_x001A_s money. The facility failed to provide a safe environment resulting in the loss of Resident #1_x001A_s money. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC133313,70A288,ALF,5/4/2013,"Reported Perpetrator 2 (RP2) accidentally gave the wrong dosage of medication to Resident #1, who realized it immediately. Resident #1 was sent to the hospital for observation and returned to the facility with no long term ill effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC133514,70A288,ALF,6/6/2013,"Between 06/06/13 and 06/10/13, money was taken from Resident #1's apartment and jewelry was taken from Resident #2 and #3's apartment. The value of the items stolen was reported to be substantial. All of the items were in locked drawers, which were broken in to. The facility was unable to determine who took the money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the resident's belongings, which is considered Financial Exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BC149236,70A288,ALF,11/28/2013,"Resident #1 reported missing approximately $50 from a locked drawer in her/his room. During the investigation, a previous incident of theft was reported to the facility a year prior and the resident was reimbursed. A resident was suspected, but investigation was unable to determine who took the money. The facility failed to ensure a safe environment resulting in the loss of resident property. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BC150131,70A288,ALF,12/24/2014,Resident #1 did not receive specific medications on two separate occasions. There was no negative outcome as a result. The facility failed to ensure medications were administered as ordered and is a violation of Oregon Administrative Rules.,2,,,, +RD118593,70A289,ALF,11/14/2011,"Resident #1 reported that over the last year, Reported Perpetrator 2 (RP2) had attempted to kiss him/her several times and grabbed his/her breast on one occasion; however could not recall specific times or days of these events. Resident #1 was alert and oriented to person, place and time and was able to consistently report the same story. RP2 denied the allegation; however reported that he/she hugged residents on a regular basis including Resident #1.",2,0,,, +RD129069,70A289,ALF,12/17/2011,Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan requiring a two person. Resident #1 suffered a knee sprain.,2,0,Not Substantiated,Substantiated,Neglect +BO120005B,70A289,ALF,3/16/2012,Resident #1 was incontinent of urine and had been found more than once urine soaked and cold in his/her bed. The facility failed to provide appropriate care and failed to care plan toileting needs. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BO120005D,70A289,ALF,3/16/2012,Resident #1 had five documented falls between 1/22/12 and 2/22/12. The facility failed to care plan appropriately for falls and failed to assess and determine interventions needed.,2,0,,,Neglect +RD121057,70A289,ALF,8/18/2012,"Resident #1 was care planned for safety checks to be conducted every two to three hours when he/she was alone in his/her apartment. Resident #1 was found injured on the floor of the bathroom from an unknown period of time between 1:30am and 9:30am on 8/18/12. Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) were aware of the care plan; however failed to follow the care plan. Resident #1 was transported to the hospital and diagnosed with fractured ribs, a collapsed lung and blood pooled between the chest cavity and ribs. RP2 and RP3 are found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Neglect +RD120980,70A289,ALF,8/9/2012,"Resident #1 discovered approximately $300 missing from where he/she kept it in his/her room. He/she kept his/her door locked and had not told any staff about the money. Staff were interviewed; however no suspected perpetrator was identified. An unknown person is responsible for the theft of Resident #1's money, constituting financial abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +RD121031,70A289,ALF,8/15/2012,"Resident #1, Resident #2, and Resident #3 discovered money missing from their respective apartments. Staff were interviewed; however no suspected perpetrator was identified. An unknown person is responsible for the theft of Resident #1's money, constituting financial abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +BO121453,70A289,ALF,9/2/2012,"Resident #1 was administered another residents_x001A_ medication resulting in a low blood pressure reading and he/she was transported to the hospital for observation. The facility failed to maintain a safe medication administration system and failed to investigate and notify the local APD/AAA office. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +RD132961,70A289,ALF,3/21/2013,"It was determined money was taken from a locked drawer in Resident #1's room. The facility was unable to determine who took the money. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. An unknown person took the money, which is considered theft and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +CO13130,70A289,ALF,11/7/2013,"The Facility failed to evaluate and refer to the Facility RN, and failed to ensure an RN assessment was conduction when Resident #5 experienced a significant change of condition related to weight loss. Resident #1 experienced further weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD145576,70A289,ALF,12/25/2013,"Resident #1's service plan called for assistance with showers twice a week. The facility failed to shower Resident #1 for 11 days between 12/13/13 through 12/24/13. Resident #1 was noted to have a strong odor of feces at the end of the 11 days. This failure is considered neglect of care which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BO146768,70A289,ALF,4/1/2014,"Resident #1 was a fall risk and had falls with injuries. The facility failed to care plan appropriately for falls and failed to intervene when Resident #1's condition changed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +CO14157,70A289,ALF,8/15/2014,"The facility failed to provide effective administrative oversight regarding residents quality of care and services as evidenced by the re-licensure survey revisit #2 (#LJL814) findings completed on July 22, 2014. See ALFCD14-004 for more details.",3,0,,,Neglect +BO147733,70A289,ALF,7/8/2014,Resident #1's care plan did not provide clear direction on providing care to him/her to escort or not to meals. Resident #1 would become confused and not remember to get to the dining room. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO135339,70A289,ALF,8/9/2014,"Resident #1 was left in soiled garments for an extended amount of time resulting in unreasonable discomfort. The facility failed to ensure staff provided care to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BO147732,70A289,ALF,8/27/2014,"The facility failed to monitor Resident #1 and Resident #2 which resulted in a physical altercation between the two. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BO148884E,70A289,ALF,8/15/2014,Resident #5 was only showered two times during the month. The facility failed to ensure he/she maintained reasonable hygiene.,2,,,, +BO148884I,70A289,ALF,8/15/2014,"Resident #9 was awoken by a stranger and has made a lasting impression on him/her and feared for her safety. The facility failed to take reasonable precautions and care plan to ensure and assure Resident #9's safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,, +BO150730,70A289,ALF,2/2/2015,"Reported Perpetrator 2 (RP2) stole Resident #1's debit card and charged a total of approximately $1,390. RP2's actions are considered theft and constitute financial exploitation. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BO151314,70A289,ALF,3/25/2015,The facility failed to provide a safe medication administration system as there was confusion of where Resident #1's pain medications were. The facilities failure exposed Resident #1 to potential harm and the failure is a violation of Oregon Administrative Rules.,2,,,, +BO153346,70A289,ALF,9/17/2015,Resident #1 was not administered his/her medications on 9/14/15. The facility failed to ensure a safe medication administration system and failed to ensure proper medication administration record documentation. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +BC116332A,70A290,ALF,5/13/2010,"Residents of the Facility were being approached by a Facility staff member, Reported Perpetrator #2 (RP2), to purchase items and invest their money in business ventures. It was unclear to what extend RP2 sold items to Facility residents or received money, however it was determined to have taken place.",2,0,,,Financial abuse +BC116332B,70A290,ALF,5/13/2010,"Facility staff were aware that a staff member, Reported Perpetrator #2 (RP2) was engaging in inappropriate financial transactions with Facility residents. The Facility did not notify the Department of the potential abuse occuring as a result of RP2's activities.",2,0,,, +BC129501,70A290,ALF,3/6/2012,"At approximately 1:30 AM, Resident #1 and Resident #2 went to the medication room to request PRN pain medication. RP2 was asleep in the locked medication room and attempts to wake her/him up were unsuccessful. W2 arrived and was able to wake RP2 up after 20 minutes of pounding on the door. The facility failed to have a qualified, awake caregiver resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC120693,70A290,ALF,8/2/2010,"Resident #1 had a physician's order for administering eye drops and was recently observed that the resident's eyesight declined significantly. Facility documentation indicated that Resident #1's medication was being administered as ordered, however additional documentation revealed the facility failed to timely reorder the eyedrop medication to support the administration of the eyedrops as ordered. The facility failed to administer medication as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC133031B,70A290,ALF,3/14/2013,"Resident #1's prescription for pain medication expired and the facility failed to have it re-filled prior to the expiration date, resulting in Resident #1 being without his/her medication for a day. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC133606B,70A290,ALF,6/23/2013,"Resident #1 had a chronic infection and was prescribed a topical medication. Facility staff allowed Resident #1 to keep the medication in his/her room and self-administer, even though Resident #1 did not have a physician's order to do so. In addition, facility staff signed Resident #1's Medication Administration Record as if they administered the medication to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC148840,70A290,ALF,10/3/2014,Reported Perpetrator #2 (RP2) placed Witness #2's medication on a table shared with Resident #1. RP2 failed to watch Witness #2 take the medication and exposed Resident #1 to potential harm. This failure is considered neglect of care which constitutes abuse. The facility failed to administer a safe medication administration system. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +BC147559A,70A290,ALF,6/22/2014,"Reported Perpetrator #2 (RP2) inappropriately sexually touched Resident #1, and is responsible for sexual abuse. The facility failed to protect Resident #1 from inappropriate sexual touching. This failure is a violation of resident rights, and is considered neglect of care resulting in sexual abuse.",4,2500,Substantiated,Substantiated,Sexual abuse +BC147559B,70A290,ALF,6/22/2014,"Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) had intercourse in front of Resident #1, which constitutes sexual abuse. The facility failed to protect Resident #1 from being exposed to inappropriate sexual activity. This failure is a violation of resident rights, and is considered neglect of care resulting in sexual abuse.",3,2500,Substantiated,Substantiated,Sexual abuse +BC150717,70A290,ALF,3/16/2015,"The facility failed to keep the assistive opening system for the facility's front doors operational. Resident #1 was having trouble getting through the doors without assistance. When the doors were opened Resident #1's scooter accelerated causing Resident #1 to fall, and sustain a fractured leg. This failure is a violation of resident rights, and is considered neglect of and constitutes abuse.",3,300,,,Neglect +BC151287,70A290,ALF,5/10/2015,"The facility failed to administer Resident #1_x001A_s medication as ordered. Resident #1 went more than 24 hours without pain medication, and experienced increased pain and discomfort as a result. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC153154,70A290,ALF,10/9/2015,"The facility failed to administer Resident #1's medication as ordered. Resident #1 was not given his/her pain medication in a timely manner, and experienced increased pain and discomfort as a result. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +BC152936C,70A290,ALF,9/20/2015,"The facility failed to answer Resident #1's call light in a timely manner. Resident #1 had to wait an hour in soiled garments as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BC153482,70A290,ALF,11/5/2015,"The facility failed to administer Resident #1's medication in a timely manner. Resident #1 was not given his/her pain medication timely, and experienced increased pain and discomfort as a result. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +HB129701,70A291,ALF,4/5/2012,RP2 administered Resident #1 twice the ordered dose. Facility documentation showed no information related to the medication error. The facility failed to ensure resident records were accurate after medication error occurred. There was no harm as a result of the error. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB129708,70A291,ALF,4/6/2012,"Resident #1, #2 and #3 were care planned as full assist with toileting needs and required checks every 2-3 hours. Each resident was found to be soaked in the same depend for over 10 hours on a least one occasion based on last documented check. The facility failed to assist residents with toileting resulting in incontinence. The failure is a violation of resident rights is considered neglect of care and constitutes abusse.",2,0,,,Neglect +HB133500,70A291,ALF,6/9/2013,"Resident #1 has a diagnosis related to memory impairment and was care planned to require assistance with bathing. On or about June 9, 2013, staff attempted to bathe Resident #1. Resident #1 became very resistive and Witness #1 advised RP2 to wait while she/he notifies other staff of the situation. When Witness #1 and Witness #2 returned, RP2 had given Resident #1 a shower. Resident #1 was observed with a skin tear and told staff she/he had been pushed against a wall. The facility failed to protect Resident #1 from rough treatment resulting in harm. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for rough treatment, and is considered physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +HB133359,70A291,ALF,5/30/2013,"Resident #1 required a one person transfer with assistive device and two person repositioning assistance every 2-3 hours. In room directions required staff to keep mobility assistive device in another room, out of Resident #1's reach. On the evening of May 29, 2013, Witness #3 assisted Resident #1 to the ground after observing Resident #1 unsuccessfully attempting to self-transfer to the assistive device. Witness #3 and Witness #4 assisted Resident #1 to her/his bed. Facility staff did not complete repositioning of Resident #1 as care planned that evening. The next morning, Resident #1 was transported to the hospital for treatment of a fractured leg after complaints of pain and observation of swollen and discolored leg. The facility failed to ensure appropriate services were provided as care planned resulting in moderate harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB134113,70A291,ALF,8/14/2013,"Resident #1 had a limited prescription for narcotic pain medication three times a day. Facility staff stopped administering the medication for 24 hours. Resident #1 suffered pain and experienced withdrawal symptoms. The facility failed to provide a safe medication administration system resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB146065,70A291,ALF,2/12/2014,Resident #1 has a diagnosis related to memory impairment and history of elopement. Care plan directed staff to provide visual checks every 2-3 hours. Resident #1 was reported missing around 4:00 AM and notified LEA that she/he was last seen at 6:30 PM. Resident #1 was later discovered unharmed and sleeping in an empty apartment bed. The facility failed to ensure Resident #1's care plan was followed resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS105251,70A292,ALF,9/14/2010,"The Facility failed to provide a safe environment to protect residents from financial exploitation resulting in Resident #1_x001A_s loss of money. Between exchanges among Reported Perpetrator 2 and Reported Perpetrator 3, Resident #1_x001A_s money went missing. The Facility_x001A_s failures are a violation of resident rights, are considered financial exploitation and constitute abuse.",3,400,Substantiated,Substantiated,Financial abuse +MS116466,70A292,ALF,3/3/2011,Resident #1 was an accurate reporter and reporting personal items missing; however unsure of exactly when they went missing. His/her items were never found.,2,0,,,Financial abuse +CO11114,70A292,ALF,8/4/2011,"The Facility failed to refer to the RN for assessment as well as failed to provide an RN assessment; evaluate interventions or monitor Resident #5 who experienced a worsening pressure ulcer. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS117659,70A292,ALF,8/8/2011,The facility failed to provide a safe medication administration and documentation system when discovered that Resident #1 had not been receiving his/her daily prescribed medication for approximately two months.,2,0,,, +MS116378A,70A292,ALF,4/7/2010,"Resident #1's care plan indicated staff and private pay caregivers to assist him/her will all mobility, including the ambulation assisted device. On April 7, 2010, Resident #1 was left alone in his/her ambulation assisted device; fell out of the device to the floor where he/she was found. Resident #1 suffered a fractured hip. + + + +The Notification of Findings was completed at a later date (A civil penalty was not issued) due to the extended period of time between the incident date and processing by the Department.",3,0,,,Neglect +MS117464,70A292,ALF,7/14/2011,An unknown individual took a large sum of cash money and approximately 20 narcotic pain medication pills from Resident #1's pants pocket in the night between 7/14/11 and 7/15/11.,2,0,Not Substantiated,Substantiated,Financial abuse +MS116378B,70A292,ALF,4/7/2010,"Resident #1 was not administered pain medications as frequently as allowed by prescriptions; thus suffering continued pain and became agitated. + + + +The Notification of Findings was completed at a later date (A civil penalty was not issued) due to the extended period of time between the incident date and processing by the Department.",3,0,,,Neglect +MS118470,70A292,ALF,10/12/2011,The facility failed to provide a safe medication system to ensure Resident #1 was administered the correct dosage of his/her medication. Resident #1 was administered the incorrect dose of a medication.,2,0,,, +MS118456,70A292,ALF,11/13/2011,Resident #1 was care planned and known to enter resident's room and staff to redirect. Resident #2 was care planned and known to get upset and physical when other residents enter his/her room; and staff to monitor and redirect residents away from his/her door. Resident #1 entered Resident #2's room and urinated on the floor. Resident #2 punched Resident #1 in the nose causing a nose bleed. The facility failed to provide a safe environment resulting in a resident to resident altercation.,2,0,,,Neglect +MS129441A,70A292,ALF,3/9/2012,Resident #1's care needs increased and the facility failed to provide services as his/her needs increased. The failures are a violation of Oregon Administrative Rules.,2,0,,, +MS129441B,70A292,ALF,3/9/2012,"Resident #1's assistive devices were placed in front of his/her bed and the mattress was placed on the floor preventing him/her from getting out of bed. The facility did not have physician's orders for this restraint. The failure is a violation of resident rights, is considered a wrongful use of physical restraint of an adult and constitutes abuse.",2,0,,,Restraints +MS129441C,70A292,ALF,3/9/2012,"Resident #1's care plan had not been updated to reflect the frequency of his/her falls; and did not reflect accommodation of his/her round the clock needs, including nighttime toileting needs. The facility failed to properly plan care. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS129706,70A292,ALF,4/7/2012,"On 4/7/12, Reported Perpetrator 2 (RP2) was observed slapping Resident #1 in the face and ""throwing"" him/her into the wheeled assisted device; however RP2 denied this. Resident #1 was later observed to have injuries to the left hand, and left and right forearms. RP2 is responsible for physical abuse causing injuries to Resident #1. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +MS121154,70A292,ALF,9/22/2012,Resident #1 was cognitively impaired and would easily get agitated. Reported Perpetrator 2 (RP2) sat by Resident #1 and popped some bubble wrap. Resident #1 became agitated and told RP2 to stop popping the bubble wrap. Resident #1 was aggravated the rest of the evening and refused his/her 8pm medication due to his/her agitation. RP2 is responsible for the emotional harm caused to Resident #1. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated, +MS120547,70A292,ALF,7/17/2012,The facility failed to follow physician's orders for Resident #1's medications. The failure is a violation of Oregon Administrative Rules.,0,0,,, +MS132445,70A292,ALF,2/20/2013,"It was reported Resident #1 had an un-witnessed fall in his/her room. Resident #1's Care Plan stated he/she required assistance with mobility, ambulation, and transfers. Resident #1 had a mobility device, but used it incorrectly. The facility failed to follow Resident #1's Care Plan when staff did not assist him/her, which is considered neglect and constitutes abuse.",2,0,,,Neglect +CO13111,70A292,ALF,7/23/2013,"The Facility failed to ensure an RN assessment was conducted when Resident #1 experienced a significant change of condition. Resident #1 had a Stage III pressure ulcer that was not assessed timely. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS145582,70A292,ALF,1/1/2014,"Resident #2 was care planned to be closely monitored for wandering. Resident #1 was possessive of his/her personal belongings and had prior altercations with residents. Resident #2 wandered into Resident #1's apartment resulting in an altercation. The facility failed to follow Resident #2's care plan to closely monitor. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS121987A,70A292,ALF,12/28/2012,Resident #1 was not showered timely. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +MS121987B,70A292,ALF,12/28/2012,Resident #1's meal was not delivered to his/her room on 12/25/12 as he/she requested. He/she resorted to going to the dining room. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +MS146700,70A292,ALF,12/28/2013,"Resident #1 had approximately $4,320 in cash missing out of the lockbox from his/her room and $150 missing out of his/her bag that was on the wheelchair. He/she always kept the door locked and staff were the only others to have a key. The investigation determined an unknown individual was responsible for the loss of money, constituting financial exploitation. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",4,,Not Substantiated,Substantiated,Financial abuse +MS146836,70A292,ALF,4/14/2014,"Resident #2 had known history of aggressive behaviors towards other residents. Resident #2 pushed Resident #1 out of the elevator in Resident #1's electric wheelchair. The facility failed to appropriately implement interventions, care plan, and monitor regarding Resident #2's behavior. The failures are a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS147466,70A292,ALF,6/20/2014,"Resident #2 exposed his/her genitals to Resident #1. Resident #2 had a history of exposing his/her self to other residents and was care planned to be escorted to/from the dining room; however the caregiver was further away than should have been. Resident #1 was upset over the incident. The facility failed to follow Resident #2's care plan and failed to provide a safe environment to all other residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MF148861,70A292,ALF,10/9/2014,Resident #1 was not treated with respect and dignity by Reported Perpetrator 2 (RP2). The facility failed to ensure a safe and homelike environment and is a violation of Oregon Administrative Rules.,2,,,, +MS148629,70A292,ALF,9/22/2014,"On 9/18/2014, Resident #1 was found to be lethargic and unresponsive and was transported to the hospital where it was discovered that he/she had opiates in his/her system. Resident #1 does not take opiates; however a resident next to him/her does. All facility medications had been accounted for and no signs of opiates were found in his/her room. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS159962A,70A292,ALF,1/20/2015,Reported Perpetrator 3 (RP3) and Reported Perpetrator 2 (RP2) did not treat Resident #1 with dignity and respect. The facility failed to ensure a safe and homelike environment. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +MS159962B,70A292,ALF,1/20/2015,Reported Perpetrator 3 (RP3) did not treat Resident #2 with dignity and respect. The facility failed to ensure a safe and homelike environment. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +MS152233,70A292,ALF,7/27/2015,Reported Perpetrator 2 (RP2) administered 30 units of insulin instead of 5 units to Resident #1. He/she was transported to the hospital for treatment. RP2's actions are considered neglect of care which constitutes abuse. The facility failed to ensure a safe medication administration system which violates Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Neglect +MS164319,70A292,ALF,1/1/2016,Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) failed to treat Resident #1 with dignity and respect. The facility failed to ensure staff treated residents with respect and dignity to ensure a safe and homelike environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +OT129379,70A293,ALF,2/19/2012,"Reported Perpetrator 2 failed to intervene, and properly assess and tend to Resident #1's wounds. Resident #1 was care planned for a tab alarm while in bed; however he/she was on the safety mat on the floor with no alarm. Resident #1 suffered unreasonable discomfort. The facility and RP2 failed to provide care and a safe environment for Resident #1. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,Substantiated,Substantiated,Neglect +RD116467A,70A294,ALF,1/5/2011,"Between 1/4/11 and 1/26/11, theft of money occurred from Resident #1's and Resident #2's rooms.",3,500,,,Financial abuse +RD116467B,70A294,ALF,1/5/2011,"Between 2/7/11 and 2/10/11, theft of money occurred from Resident #3's and Resident #4's rooms.",3,0,,,Financial abuse +RD121920,70A294,ALF,11/25/2012,"The facility failed to assess and intervene, failed to monitor, and failed to follow policy and procedures when Resident #1 reported back pain and had a heating pad in his/her recliner for approximately several days. Resident #1 was transported to the hospital and suffered a first degree burn and a second degree burn on his/her back. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD133330,70A294,ALF,5/13/2013,"During a routine audit of Narcotic Logs and Medication Administration Records, Witness 2 discovered some narcotic medications for Residents #1-4 were missing during a two week span. Reported Perpetrator 2 (RP2) admitted to taking the medications. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for taking the medications, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +CO13153,70A294,ALF,11/7/2013,"The facility failed to adequately evaluate and monitor Resident 4 resulting in a pressure ulcer worsening. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD135204,70A294,ALF,10/5/2013,"Reported Perpetrator #2 (RP2) issued Resident #1 the wrong dose of medication between 10/5/13 and 10/8/13. In addition, RP2 failed to administer any medication to Resident #1 between 10/10/13 to 10/14/13. Resident #1 was sent to the ER on 10/16/14 with health complications related to the medication he/she was supposed to be receiving. RP2 was found to be responsible for neglect of care which constitutes abuse. The facility failed to ensure professional oversight of the medication and treatment administration system. This failure is a violation of Oregon Administrative Rules and a violation of Resident Rights.",3,,Not Substantiated,Substantiated,Neglect +RD134947B,70A294,ALF,10/1/2013,"In August 2013 it was discovered Resident #2 missed three doses of morning medication prior to suffering from a siezure. The medication was an anti-convulsant for Resident #2's seizure condition. Reported Perpatrator #3 failed to provide this medication, and this failure is considered neglect of care which constitutes abuse. The facility failed to ensure professional oversight of the medication and treatment administration system. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +RD134947A,70A294,ALF,10/1/2013,Reported Perpetrator 2 (RP2) failed to administer medication as ordered on 6 days between 10/1/13 and 10/15/13. Resident #1 did not suffer any ill effects. The facility failed to ensure professional oversight of the medication and treatment administration system. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +BC117512,70A295,ALF,7/14/2011,The facility failed to provide a safe environment resulting in the loss of several residents' property including narcotic pain medication and money. An unkown individual was substantiated for abuse. The failure is a violation of OARs.,2,0,Not Substantiated,Substantiated,Financial abuse +BC129550,70A295,ALF,3/16/2012,Resident #1 manages her/his own medications and keeps them secure in a locking drawer in her/his apartment. Resident #1 discovered a narcotic card containing 30 medications missing. Resident #1 locks her/his door when not in the room. The facility failed to provide a safe environment resulting in the loss of medication. An unknown person was found responsible for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +BC129273,70A295,ALF,1/23/2012,"Three narcotic cards containing a total of 93 narcotic medications for Resident #1 was sent to the facility by courier on the evening of January 23, 2012. RP2 signed for the narcotics and only logged in two of the three narcotic cards. The delivery slip could not be located and RP2 was unable to recall where the slip went. RP2 did not verify all medications were accounted for when she/he received the order. The facility failed to have a safe medication administration system resulting in the loss of medications. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for financial exploitation.",2,0,Not Substantiated,Substantiated,Financial abuse +BC120554,70A295,ALF,7/7/2012,"Medications were taken from Resident #1's locked drawer between July 6 and 16, 2012. Resident #1 had a similar incident of theft in the past. The locking drawer supplied to the resident was easily opened without a key. The facility failed to provide a safe environment resulting in the theft of medications. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for financial exploitation and is considered abuse.",2,200,Not Substantiated,Substantiated,Financial abuse +BC120602,70A295,ALF,7/5/2012,"Resident #1 returned to the facility from the emergency room with orders for a specific medication to assist with blood sugars on or about July 1, 2012. Resident #1 did not receive the medication until July 5, 2012. The facility failed to follow up to ensure medications were delivered timely resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC121444,70A295,ALF,10/15/2012,"Resident #1 reported a wallet missing from her/his room containing cash and bank cards. The wallet went missing between 2:30 and 4:00 PM on October 15, 2012. Resident #1 was in the room taking a nap at the time of the incident and recalled Witness #3 had been in there during that time taking out the trash. Resident #1 left her/his door propped open. Investigation was conducted and search revealed two more items missing from room. The facility failed to ensure a safe environment. An unknown individual was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BC133353,70A295,ALF,5/19/2013,"Resident #1 fell during the night, was on the floor, face down, with the mattress on top of him/her and was not found until 6:45 a.m. the following morning. Resident #1 had skin tears to his/her knee and shoulder. There was swelling and discoloration on his/her face. Reported Perpetrator 2 (RP2) did not assess Resident #2 until seven hours later, even though he/she was notified of the incident upon arriving at the facility around 7:30 or 8:00 a.m. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. RP2 failed to assess Resident #1 in a timely manner, which is considered neglect of care and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +BC133404,70A295,ALF,5/24/2013,"An unknown person took narcotic medications from Resident #1's apartment on two occasions. W1 said there have been other medication thefts at the facility. There was no indication of the facility implementing interventions to prevent the thefts. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the medications, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BC134250,70A295,ALF,8/26/2013,"Resident #1 was a known fall risk and care planned for frequent checks at night. Witness testimony and facility documentation revealed Resident #1 spent the night on the floor of her/his room and suffered a fractured rib and contusions from a fall. The facility failed to ensure adequate staffing to meet the care needs of residents. The failures are violations of resident rights, is considered neglect of care and constitute abuse. RP2 was not found responsible abuse.",3,250,,,Neglect +BC145793,70A295,ALF,1/5/2014,The facility failed to document and follow-up with Resident #1's treating physician related to a med change. Resident #1 went three days without a medication change and had consistently low blood sugar levels due to not receiving different medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +DL104846A,70A296,ALF,7/12/2010,The facility failed to care plan appropriately for transfer assistance for Resident #1 and Resident #2. The facility failed to care plan appropriately for falls for Resident #3.,2,0,,, +DL104846B,70A296,ALF,7/12/2010,The facility failed to provide a safe medication administration system by not securing the medication room while staff dispensed medications; and failed to provide the correct syringe for liquid medication.,2,0,,, +DL104846C,70A296,ALF,7/12/2010,Facility staff were noted to become frustrated with Resident #4 when he/she experienced verbal outbursts.,2,0,,, +DL118136,70A296,ALF,8/18/2011,"Resident #1 was taken on an outing with six other residents and one caregiver. Resident #1 wandered away, unknowingly to the caregiver, and was found walking along the road. The facility failed to assure Resident #1 was safe during the group outing, as he/she was a known elopement risk and had recent history of elopement from the facility.",2,0,,, +DL129737,70A296,ALF,4/6/2012,"Resident #1 had cognitive impairment, required frequent monitoring and supervision, was a wander risk, and wore a wanderguard bracelet. He/she had documented exit seeking attempts between 3/14/12 and 4/6/12. On 4/6/12, Resident #1 exited the facility twice in the morning and was noted to be agitated and PRN medication administered but didn_x001A_t help. Resident #1 left the facility unattended the evening of 4/6/12 and was found approximately 200 yards from the facility. Resident #1 was transported to the hospital and diagnosed with a fractured hip requiring surgery. The facility failed to assure Resident #1 was safe. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DL118151,70A296,ALF,8/28/2011,"The facility failed to provide a safe environment resulting in an altercation between Resident #1 and Resident #2, with no injuries. The failures are a violation of Oregon Administrative Rules.",2,0,,, +DL120741,70A296,ALF,8/6/2012,"The facility failed to appropriately care plan; failed to implement interventions and provide staff support; and failed to monitor residents with known behaviors and those in an established ""cliquish"" group of residents. Residents' behaviors escalated, affecting other residents, exposing residents to potential harm. The failures are a violation of Oregon Administrative Rules.",2,0,,,Neglect +DL132761,70A296,ALF,3/26/2013,Resident #2 has had verbal altercations with other residents. Resident #2 also has disruptive behaviors that affect other residents. The facility failed to address Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DL132931,70A296,ALF,4/11/2013,Resident #1 and Resident #2 were involved in an altercation. Both residents sustained superficial rug burns. The facility failed to address Resident #1 and Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DL132394,70A296,ALF,2/10/2013,"Resident #1 was diabetic and transported to the hospital after being found semi-conscious in his/her room. Documentation revealed Resident #1's glucose levels were low two days prior to going to the hospital and facility staff failed to check his/her insulin twice the day before going to the hospital. The facility failed to administer medical treatment as ordered. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted but was not issued, due to the fact that the incident occurred prior to the change in ownership.",3,,,,Neglect +DL133376,70A296,ALF,6/3/2013,RP2 administered the wrong medications to Resident #1 resulting in transportation to the hospital and treatment. Resident #1 experienced nausea and vomiting. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. RP2 was held responsible for neglect of care and constitutes abuse.,3,,Not Substantiated,Substantiated,Neglect +DL133716,70A296,ALF,7/6/2013,"Resident #1's service plan included extra housekeeping but did not include assistance with daily bed making. Witnesses reported Resident #1's room was filthy; the mattress was stained and black, the walls had bodily fluids all over them and the room smelled like urine. The facility failed to provide appropriate housekeeping services. The failure is a violation of Oregon Administrative Rules.",2,,,, +DL133494,70A296,ALF,6/11/2013,"Resident #2 had known verbal and physical aggressive behavior towards Resident #1 when intoxicated. The facility entered into a managed risk agreement with Resident #2 to prevent negative behavior affecting Resident #1. Resident #2 continued to exhibit aggressive behaviors towards Resident #1 while intoxicated. The facility failed to provide a safe environment resulting in harm. The failure is a violation of resident rights, is considered neglect of care resulting in physical abuse. A civil penalty was not issued due to a change of ownership on July 1, 2013.",3,,,,Neglect +DL105260,70A296,ALF,9/15/2010,"Resident #1 experienced multiple falls. The facility failed to adequately monitor and care plan related to falls. The failure is a violation of Oregon Administrative Rules. The report is being issued at a later date due to the timeframe between the investigation date and when it was received by the Depatment. The incident also occurred prior to the change of owner on July 1, 2013.",2,,,, +DL146738,70A296,ALF,4/13/2014,"RP2 administered Resident #1 another resident's medication resulting in transportation to the hospital for observation. The facility updated their medication system to reduce future medication errors. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 was not held responsible for abuse.",2,,,,Neglect +CO14117,70A296,ALF,5/23/2014,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the re-licensure survey (#DFL011) findings completed on May 23, 2014.",3,0,,,Neglect +DL147867,70A296,ALF,7/18/2014,"Resident #1 had a medical condition that required specific nursing and care staff services for her/his feet. On June 24, 2014 Resident #1's right toe was clipped and a bandage was put on. On July 17, 2014, wounds were discovered on Resident #1's toes that required outside treatment. There was no documentation related to Resident #1's feet/toes between June 24th and July 17th, 2014. Facility failed to ensure Resident #1's service plan was followed for foot care and failed to provide oversight and monitoring of toe wounds. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DL148353,70A296,ALF,9/1/2014,"Resident #1 had a history of increased aggressive behavior and known to get upset with others over the television in the common room. Resident #2 plays the piano on a regular basis which is also located in the common room. Resident #1 became aggressive and physically harmed Resident #2 after the television was turned off. The facility failed to ensure a safe environment resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DL148583,70A296,ALF,9/13/2014,"Resident #1 had a history of aggressive behavior and was care planned to address it. RP2 did not follow the behavior plan. Resident #1 received minor injuries, but it is unclear if the injuries occurred prior to RP2's involvement. Investigation concluded that the facility failed to ensure the care plan was followed and is a violation of Oregon Administrative Rules.",2,,,, +DL149051,70A296,ALF,10/24/2014,"Resident #1 had a history of verbally inappropriate behavior. On or about October 24, 2014, Resident #1 assaulted Resident #2 after a verbal altercation. The facility failed to ensure a safe environment and adequately address Resident #1's behavior. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility also failed to keep an accurate Medication Administration Record for Resident #1 and is a violation of Oregon Administrative Rules.",2,,,,Neglect +AL116239,70A297,ALF,10/30/2010,"RP2 failed to administer Resident #1's her/his new pain patch, but documented that she/he did resulting in the resident experiencing unreasonable discomfort for two days. The facility failed to ensure Resident #1's medication was administered as ordered.",2,0,Not Substantiated,Substantiated,Neglect +AL117459,70A297,ALF,1/8/2011,"On two separate occassions, Resident #1 was given another resident's medication. The medications given were the same as what Resident #1 normally took. The facility failed to provide a safe medication administration system resulting in the potential for harm.",2,0,,, +AL117504,70A297,ALF,11/22/2010,"The facility misplaced Resident #1's medication. Resident #1 administered her/his own medication, however the facility failed to deliver the medication to the resident in a timely manner resulting in three days of not getting the medication. The facility failed to provide a safe medication administration system resulting in the potential for harm.",2,0,,, +AL117932,70A297,ALF,7/11/2011,"On July 11, 2011 Resident #1 was discharged from the hospital with a new order for liquid laxative due to fecal impaction, however was not administered until July 18, 2011. The facility failed to administer medication as ordered resulting in the potential for harm. The failure is a violation of OARs.",2,0,,, +AL129973,70A297,ALF,9/22/2011,"Resident #1 and Resident #2 had a history of verbal altercations and sat in the same table for meals. On September 22, 2011, staff observed Resident #1's reaction to Resident #2's ridicule of her/him and failed to intervene until after the verbal altercation escalated into physical. The facility failed to address residents' behaviors resulting in negative behavior escalating and affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AL120200,70A297,ALF,11/1/2011,Resident #1 was administered another resident's medication. The facility contacted appropriate parties and monitored the resident with no observable negative outcome. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AL121285,70A297,ALF,6/12/2012,"The facility failed to provide appropriate oversight and monitoring after Resident #1 experienced a fall with injury resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +AL121532,70A297,ALF,6/25/2012,A call light was pulled by Witness #2 after Resident #1 was found on the floor. Witness #2 assisted Resident #1 to a chair and they proceeded to wait approximately 25 minutes before the call light was answered. The facility failed to ensure the call light was answered in a timely manner resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +AL150810,70A297,ALF,7/16/2014,Reported Perpetrator #2(RP2) failed to administer 1 dose of pain medication to Resident #1. Resident #1 experienced increase pain symptoms as a result. RP2 is responsible for neglect of care which constitutes abuse. The facility failed to administer a safe medication administration system. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +AL151917,70A297,ALF,12/5/2014,"The facility failed to adequately monitor Resident #2 in relation to his/her aggressive behavior. Resident #2 hit Resident #1 on the arm. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MV164379,70A297,ALF,1/21/2016,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS116267,70A298,ALF,12/25/2010,Resident #1's gifted chocolates were last seen on 12/25/10 and were discovered missing from his/her room on 12/26/10.,2,0,Not Substantiated,Substantiated,Financial abuse +MF121557,70A298,ALF,11/7/2012,Reported Perpetrator 2 (RP2) was verbally inappropriate with Resident #1 causing him/her emotional harm. RP2 is found responsible for verbal abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +ES105654B,70A299,ALF,10/30/2010,Complainant reported the facility was not assisting Resident #1 with cutting up her/his meat as directed by the physician. Facility documentation revealed that the physician sent an order for Resident #1 to have a modified diet. The facility did not clarify the order and Resident #1 did not get assistance with cutting her/his meat as needed. The wrongdoing was substantiated.,2,0,,, +ES104525,70A299,ALF,5/26/2010,Resident #1 declined over several days at the end of May 2010 and staff were directed to push fluids and check every two hours. Resident #1 was found urine soaked twice on her/his recliner and several food trays left in room. The facility failed to ensure Resident #1 was being cared for as directed resulting in harm.,2,0,,,Neglect +ES105270,70A299,ALF,9/13/2010,"The facility failed to provide a safe environment resulting in the loss of resident property. There were two sets of facility keys missing with no indication of locks being changed to prevent individuals from accessing unauthorized areas. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES116253A,70A299,ALF,1/22/2011,RP2 was physically rough with Resident #1 while providing peri care because the resident used the call light multiple times.,2,0,Not Substantiated,Substantiated,Physical Abuse +ES116253B,70A299,ALF,1/22/2011,RP2 yelled at Resident #1 and was verbally inappropriate because the resident used the call light multiple times for assistance. RP2 was found responsible for verbal abuse.,2,0,Not Substantiated,Not Substantiated,Verbal/Mental abuse +ES116553,70A299,ALF,3/14/2011,Resident #1 had 180 narcotic pills taken from the lock box in her/his room. Facility Administrator and Resident #1's family were the only ones who had access to the lock box. The facility failed to notify local law enforcement or conduct an internal investigation after the theft was discovered. The failure is a violation of OARs. Investigation was unable to conclude who was responsible for the theft and the abuse was apportioned to an unknown individual.,3,0,Not Substantiated,Substantiated,Financial abuse +ES116908,70A299,ALF,4/26/2011,"Resident #1 was issued a heart monitoring machine to be worn at all times on April 26, 2011. RP2 signed for the machine and it was lost for eight days before Resident #1 was able to use it. There was no observed harm as a result of the delayed use of the heart monitor.",2,0,,, +ES116579,70A299,ALF,3/18/2011,Resident #1 pointed out that RP2 was providing the wrong medication. Resident #1 refused to take the medication. The facility attempted to administer the wrong medication resulting in the potential for harm.,2,0,,, +ES117352,70A299,ALF,6/10/2011,"Resident #1 fell over in her/his wheelchair while being transported by facility vehicle. Internal investigation revealed the supporting straps used to secure Resident #1's wheelchair had been improperly adjusted resulting in the wheelchair tipping over. Resident #1 sustained a laceration requiring multiple stitches and three fractured ribs. The facility failed to appropriately train staff resulting in moderate harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES116263,70A299,ALF,1/31/2011,Resident #1 discovered a $50.00 gift card missing from her/his room on 1/31/11. Resident #1 locks her/his door whenever not in apartment. Investigation conducted and was unable to determine who took the gift card. The facility failed to provide a safe environment resulting in the loss of property. An unknown individual was found responsible for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES117686,70A299,ALF,8/5/2011,The facility failed to provide a safe environment resulting in the loss of 50+ narcotic medications from Resident #1's room. The facility is now managing Resident #1's medication. An unknown individual was found substantiated for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES116742A,70A299,ALF,3/26/2011,Facility staff were asked to check on Resident #1 at 11:00 AM. Witness #3 checked on the resident at 2:00 PM to administer medications with no observable concerns. Witness #3 was not told to check on Resident #1. At 2:30 PM Resident #1 was check on again at Witness #7's request and found to be in distress and required transporation to the hospital for treatment. The facility failed to communicate necessary information resulting in the potential for harm.,2,0,,, +ES116742C,70A299,ALF,3/26/2011,"Complainant reported that Resident #1 did not receive medications as required on two occasions as documented on the resident's Medication Administration Record. Facility indicated that the medications were administered, however staff failed to document appropriately. The facility failed to provide a safe medication administration system resulting in the potential for harm.",2,0,,, +ES116760,70A299,ALF,4/9/2011,RP2 refused to immediately assist Resident #1 with toileting when requested. Resident #1 had to wait at least 20 minutes for assistance. The facility failed to ensure Resident #1 received toileting assistance in a timely manner and is a failure of OARs.,2,0,,, +ES117902,70A299,ALF,9/4/2011,"The facility failed to provide a safe medication administration system resulting in the loss of Resident #1's medication. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. Both the facility and unknown individual was apportioned abuse.",2,0,Substantiated,Substantiated,Financial abuse +ES117868,70A299,ALF,8/18/2011,Resident #1 left the facility unattended and was later found fatigued several blocks away. Resident #1 had a history of leaving the facility and unable to return due to fatigue. The facility failed to provide a safe environment resulting in the potential for harm.,2,0,,, +ES118508,70A299,ALF,11/21/2011,Resident #1 reported a missing I-Pod nano. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES118460,70A299,ALF,11/6/2011,"Resident #1 did not receive ordered medication for two days. The facility failed to timely notify Resident #1's physician after her/his prescription could not be filled resulting in the resident being sent to the hospital for chest pains. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES118486,70A299,ALF,10/22/2011,Resident #1 reported over 100 narcotic medications missing from the locked drawer in her/his room. Upon investigation it was discovered the lock could be easily opened without using a key. The facility failed to provide a safe environment resulting in the loss of resident's medication. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES118487,70A299,ALF,11/11/2011,The facility failed to timely reorder Resident #1's pain medication resulting in the resident experiencing pain for approximately 12 hours before receiving relief.,2,250,,,Neglect +ES118533,70A299,ALF,11/19/2011,"Five rings went missing from Resident #1's room during her/his stay at the hospital. Investigation was conducted, but no suspects were found. The facility failed to provide a safe environment. An unknown individual was found substantiated for financial abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +ES128925,70A299,ALF,1/12/2012,"A delivery of pain medication for Resident #1 was signed in by RP2. RP2 lost keys to the medication room and after finding the keys at the front desk, Resident #1's pain medication was missing. The facility failed to provide a safe medication administration system resulting in the loss of Resident #1's pain medication. An unknown person was found responsible for financial exploitation and is considered abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +ES129288,70A299,ALF,2/19/2012,RP2 was verbally inappropriate with Resident #1 when providing assistance. The facility failed to ensure Resident #1 was treated with dignity and respect and is a violation of Oregon Administrative Rules.,2,0,,, +ES118617,70A299,ALF,12/3/2011,Resident #1 was administered four pain medications belonging to Resident #2. Resident #1 reported feeling nauseas after taking the medications. The facility failed to provide a safe medication administration system resulting in a negative outcome to Resident #1.,2,0,,,Neglect +ES129113,70A299,ALF,12/15/2011,"On at least two occasions, staff attempted to give Resident #1 the wrong medications. There was no documentation to address the incidents and prevent future occurrences. The failure is a violation of Oregon Administrative Rules and is a potential for harm.",2,300,,, +ES121119,70A299,ALF,9/19/2012,Resident #1 reported missing $12.00 from her/his purse. Staff enter Resident #1's room to help with toileting assistance and have access to the purse while the resident is in the bathroom. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was found responsible for financial exploitation and is considered abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES120549,70A299,ALF,7/16/2012,Resident #1 experienced agitation and medication was requested. RP3 and RP4 were observed yelling and using physical force on Resident #1 to take her/his medications. RP3 and RP4's actions exacerbated Resident #1's behaviors resulting in transporation to the hospital. The facility failed to provide a safe environment for Resident #1 and is a violation of Oregon Administrative Rules. RP3 and RP4 were found responsible for corporal punishment and is considered physical abuse.,3,0,Not Substantiated,Substantiated,Physical Abuse +ES120614,70A299,ALF,7/18/2012,Resident #1 reported cash and spouse's wedding ring taken from her/his apartment. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for financial exploitation and is considered abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES118004,70A299,ALF,9/3/2011,"Resident #1 reported over $300 worth of jewelry missing from her/his locked room. Resident #2 was suspected of the theft and believed to be suspected of other similar thefts regarding both resident and staff belongings. There is concern that a master key is missing. The facility failed to address Resident #2's behaviors and observations of possible theft and failed to take appropriate action to prevent future thefts. The failures are violations of resident rights, are considered neglect of care and constitute abuse. A civil penalty is warranted, however one was not issued due to the extended period of time between investigation date and processing by the Department.",3,0,,,Financial abuse +ES132189,70A299,ALF,1/19/2013,"Resident #1 report 50 narcotic pills missing from her/his locked room. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown person was held responsible for the theft, is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +ES120515,70A299,ALF,6/30/2012,An unknown individual is responsible for the loss of Resident #1's money from his/her room. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES132887,70A299,ALF,4/9/2013,"Resident #1 had a medical condition that required a visit to the physician. The facility made the appointment, but failed to remind or arrange for transportation. Resident #1 was identified in her/his care plan as forgetful. Resident #1 forgot to go to two appointments. The facility failed to arrange for and remind Resident #1 of her/his medical appointments resulting in the potential for harm. The failures are violations of Oregon Administrative Rules.",2,0,,, +ES132740,70A299,ALF,2/19/2013,"Resident #1 reported a brand new laptop worth approximately $700 missing from her/his room. The facility failed to provide a safe environment and conduct an internal investigation. The failures are violations of resident rights, are considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown was also held responsible for financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +ES133033,70A299,ALF,3/26/2013,"Resident #1 reported the loss of 28 narcotic pain pills from her/his locked room. The facility failed to provide a safe environment and conduct an internal investigation. The failures are violations of resident rights, are considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",2,0,Substantiated,Substantiated,Financial abuse +ES132186,70A299,ALF,4/1/2012,"The preponderance of evidence indicates Reported Perpetrator 2 (RP2) diverted narcotic pain medications, resulting in the loss of residents' narcotic medications. RP2 is found responsible for abuse. The facility failed to provide a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +ES133128,70A299,ALF,5/2/2013,"Resident #1 reported a bag missing from her/his walker. An unidentified staff member later found the bag near the facility dumpster. Resident #1's keys and wallet were removed. The following day, Resident #1's car was stolen from the facility's parking lot. The facility failed to provide a safe environment. The failures are violations of resident rights, are considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",3,400,Substantiated,Substantiated,Financial abuse +ES133151,70A299,ALF,5/5/2013,"Resident #1 reported two fishing poles and two tackle boxes missing from her/his locked room. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +ES133365,70A299,ALF,5/11/2013,"Twenty-seven (27) narcotic pills were taken from Resident #1's locked cabinet located in her/his room. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also substantiated for financial exploitation and constitutes abuse.",3,200,Substantiated,Substantiated,Financial abuse +ES133331,70A299,ALF,5/19/2013,"Medications were stolen from an unsecured locked drawer in Resident #1's room on three separate occasions. The facility failed to report or conduct internal investigations. The facility was aware of the unsecured lockable storage space and failed to fix it. The facility failed to provide a safe environment. The failures are violations of resident rights, are considered neglect of care resulting in financial exploitation and is considered abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +ES133333,70A299,ALF,5/21/2013,"Jewelry, estimated at $200-$300 was reported taken from Resident #1_x001A_s unsecured locking drawer. The facility failed to report or conduct an internal investigation. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown person was also found responsible for financial exploitation and constitutes abuse.",3,350,Substantiated,Substantiated,Financial abuse +ES133334,70A299,ALF,4/28/2013,"Resident #1 reported the loss of 27 narcotic pain medications from her/his locked room. The facility failed to conduct an internal investigation or report the investigation. The facility failed to provide a safe environment resulting in the loss of resident property. The failures are violations of resident rights, are considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +ES133539,70A299,ALF,6/7/2013,"Resident #1 reported approximately 58 pain medications missing from the lockbox in their locked room. The facility has had multiple thefts occur at the facility. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",,,Substantiated,Substantiated,Financial abuse +ES134552,70A299,ALF,9/26/2013,"Resident #1 had a physical altercation with Resident #2. Witness testimony and facility documentation revealed Resident #1 had a history of altercations with other residents. Resident #1's care plan did not address Resident #1's behaviors. The facility failed to adequately care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES134842,70A299,ALF,10/10/2013,Resident #1 was care planned as incontinent and required assistance with toileting. The facility failed to have appropriate supplies to meet resident's needs. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES120436,70A299,ALF,6/30/2012,"Resident #1 reported money missing from locked drawer in her/his room. The facility failed to provide a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for the loss of money, is considered financial exploitation and constitues abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES134072,70A299,ALF,8/7/2013,"Resident #1 requires assistance with transfers and the use of the bedpan. On one known occasion, facility staff failed to assist Resident #1 with transferring resulting in unreasonable discomfort from several hours of being left on the bedpan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES134878,70A299,ALF,7/4/2013,"Resident #1 was discovered tangled in her/his bed cane after several hours entraped. There were no documented assessments or care plan instructions related to the bed cane. The facility failed to assess and document the use of the bed cane resulting in the potential for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES134188,70A299,ALF,8/5/2013,"Resident #1 required assistance with medication management and administration. The facility failed to ensure a safe medication administration system. Resident #1 required transportation to the hospital for treatment after the facility failed to administer PRN narcotic pain medication as ordered. The facility also failed to administer Resident #1's diuretic medication resulting in shortness of breath and leg swelling. The failures are violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES134881,70A299,ALF,10/21/2013,"The facility failed to provide a safe medication administration system resulting in Resident #1_x001A_s medical condition worsening from not receiving her/his medications as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +ES135355,70A299,ALF,10/29/2013,"Resident #1 had prescribed medication for scheduled and unscheduled pain and requested one on or about October 29, 2013. RP2 documented as dispensing the medication even though she/he had not. Resident #1 continued to experience pain for several hours until another staff member administered the medication. The facility failed to ensure a medication was administered as ordered. RP2 was held responsible for neglect of care and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +ES134412,70A299,ALF,9/10/2013,Residents' medications were administered approximately 3 hours late. The facility failed to provide a safe medication administration resulting in the potential for harm. The facility also failed to provide requested documentation. The failures are violations of Oregon Administrative Rules.,2,,,, +ES134470,70A299,ALF,9/15/2013,"Resident #1 did not receive her/his diuretic medication for approximately 10 days resulting in ongoing medical issues. The facility failed to transcribed Resident #1's diuretic medication order onto her/his Medication Administration Record. The facility failed to provide a safe medication administration system. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,400,,,Neglect +ES134748,70A299,ALF,10/15/2013,"Resident #2 had a history of not liking Resident #1 and care planned to keep residents apart and supervised when sharing the same place due to a previous altercation. Resident #2 walked over to Resident #1 and engaged in an altercation in the dining room resulting in a broken nose. The facility failed to follow the care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES134746,70A299,ALF,10/15/2013,"A total of $370 worth of PIF (Personal Incidental Funds) belonging to three residents were taken from a lockbox located in the administration office. The facility failed to provide a safe environment resulting in the loss of resident money. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown person was also held responsible for financial exploitation and constitutes abuse.",3,400,Substantiated,Substantiated,Neglect +ES135332,70A299,ALF,12/8/2013,"Resident #1 experienced a decline in health and required more assistance. The facility failed to adequately care plan and follow the temporary care plan resulting in transportation to the hospital for treatment of a fractured hip from an injury fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES133985,70A299,ALF,8/1/2013,"Resident #1 had cognitive impairment and wandered throughout the building, including being observed on two known occassions outside. The facility failed to appropriately evaluate and monitor Resident #1's behavior resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES135040,70A299,ALF,10/30/2013,"Resident #1 was observed pushing Resident #2. Witness testimony revealed previous behaviors with residents. Neither care plan documents behaviors or how to address it. The facility failed to provide a safe environment resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES135168,70A299,ALF,11/7/2013,"The facility failed to assess and implement additional interventions when Resident #1 fell while being assisted to the toilet by one caregiver. Resident #1 fell a second time while being assited by one caregiver and injured his/her arm. This failure is considered neglect of care, which is considered abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES146716,70A299,ALF,4/11/2014,The facility failed to implement additional interventions around Resident #1's behavior of dropping all his/her weight on facility staff during assisted transfers. Resident #1 did this again and facility staff were forced gently lower Resident #1 to the floor without injury. This failure is a violation of Oregon Administrative Rules.,2,,,, +CO14199,70A299,ALF,10/3/2014,"Preliminary Information from the Assisted Living Facility re-licensure survey (#CWPV11) completed on October 3, 2014 determined that the Facility is not in substantial compliance with the Oregon Administrative Rules for Assisted Living Facilities and that the Facility_x001A_s noncompliance placed residents at harm or risk for harm. The failures are a violation of Oregon Administrative Rules. See ALFCD14-006 for more details",,0,,, +ES148046,70A299,ALF,8/4/2014,The facility failed to provide Resident #1 with his/her medication after his/her meal as was prescribed. The medication was given before the meal was served. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES148825,70A299,ALF,10/2/2014,"Money went missing from Resident #1's room. An unknown person was found to have taken the money, and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES148824,70A299,ALF,10/2/2014,"The facility failed to adequately intervene during a resident to resident altercation. Resident #1 and Resident #2 got into an altercation. Two facility staff members in the room were not trained on how to handle resident to resident altercations. The altercation continued until a different staff member was summoned to stop it. Resident #1 sustained skin tears during the altercation. This failure is considered neglect of care, constitutes abuse, and violates Oregon Administrative Rules.",2,,,, +ES149452,70A299,ALF,11/26/2014,"The facility failed to administer medication as ordered for Resident's #1, 2, 3, 4, 5, and 6. These residents did not receive medication for a day due to the facility failing to fill their prescriptions at the pharmacy in a timely manner. Residents expressed increased pain as a result of missing a day of medications. This failure is a violation of residents rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +ES149089,70A299,ALF,10/29/2014,"Resident #1 had money go missing from his/her room. An unknown individual took the money and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES148828,70A299,ALF,10/4/2014,The facility failed to administer medication as ordered for Resident #1 and Resident #2. Both residents received medication late. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES150900,70A299,ALF,4/9/2015,"The facility failed to intervene when Resident #1 became agitated with Resident #2. Resident #1 got into an altercation with Resident #2 and punched him/her repeatedly. This failure is considered neglect of care, which constitutes abuse and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES150545,70A299,ALF,3/11/2015,"The facility failed to adequately ensure Resident #1 received appropriate assistance when getting dressed. Resident #1 experienced increased pain when he/she had to reach back further than he/she could to put on a sweater. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES152681,70A299,ALF,8/24/2015,"Resident #1 items go missing from the facility safe. The items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES153968,70A299,ALF,12/14/2015,"Resident #1 and Resident #2 had money go missing from their rooms. The money was taken by an Reported Perpetrator #2 (RP2) and RP2 is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect the resident's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +NB105489,70A302,ALF,10/13/2010,Resident #1 did not lock his/her apartment door and the lock box in his/her room was not secured and accessibility was relatively easy. Resident #1's money went missing from his/her locked box.,2,0,,,Financial abuse +NB117485,70A302,ALF,7/19/2011,Resident #1 and Resident #2 were not administered their ordered medications.,2,0,,, +CO11115,70A302,ALF,9/8/2011,"The Facility failed to ensure Resident #1 was monitored and evaluated according to his/her needs, failed to ensure his/her significant change of condition was referred to the RN as well as failed to provide an RN assessment. Resident #1 suffered wounds that worsened, required hospitalization due to a wound infection and experienced unrelieved pain. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NB117213,70A302,ALF,5/28/2011,Resident #1 and Resident #2 were not administered medications as ordered by Reported Perpetrator #2 or Reported Perpetrator #3.,2,0,,, +NB117650,70A302,ALF,7/30/2011,The Facility failed to provide a safe medication administration system. These failures resulted in Resident #1 not receiving his/her ordered medication and are a violation of resident rights.,2,250,,, +NB118283,70A302,ALF,10/16/2011,"Between 8/29/11 and 9/22/11, Resident #1 was administered 5 mg of a daily dosage of medication, instead of the 10 mg as prescribed. Between 10/12/11 _x001A_ 10/16/11, Resident #1 was not administered this medication at all. Resident #1 did not show any signs of adverse reactions.",2,0,,, +NB118448,70A302,ALF,11/14/2011,RP2 gave Resident #1 her/his personal narcotic pain medications as the resident was having difficulty refilling her/his. The facility failed to ensure safe environment resulting in the potential for harm.,2,0,,, +NB118072,70A302,ALF,9/12/2011,"Resident #1 reported money missing from his/her security drawer, which was discovered to be faulty with available access to anyone. Resident #2 reported money missing from his/her pants pocket that he/she counted the prior day. The theft of money occurred by actions of an unidentified individual. The facility failed to provide a safe environment and a functional safe security drawer.",2,0,Substantiated,Substantiated,Financial abuse +NB118720,70A302,ALF,12/19/2011,Resident #2 was not administered his/her prescribed evening medication dose on 12/17/11. Resident #1's medication was not available when he/she needed them to leave the facility; the prescription was satellited and delivered moments before he/she was leaving the facility. The facility failed to have medication available timely to administer medications as ordered.,2,0,,, +NB129001,70A302,ALF,1/8/2012,"Reported Perpetrator 2 (RP2) did not treat Resident #1 and Resident #2 with respect and dignity, and failed to ensure a homelike environment. RP2 restricted access to a public restroom for resident use. The failure is a violation of resident rights and is a violation of Oregon Administrative Rules.",2,0,,, +NB120430,70A302,ALF,7/3/2012,Resident #1 was not administered his/her medication as ordered; however did not suffer any ill affects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB121577,70A302,ALF,11/10/2012,"Reported Perpetrator 2 (RP2) administered Resident #1 another residents' medication. He/she experienced light headedness, dizziness and vomited. RP2 administered Resident #2's medication later than prescribed. RP2 is found responsible for neglect of care. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Neglect +NB132726,70A302,ALF,3/19/2013,The facility failed to administer Resident #1's ordered medication resulting in one dose missed. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB133160,70A302,ALF,5/7/2013,Resident #1 was administered a medication along with another medication when it was ordered not to take them together. His/her medication administration record (MAR) had errors that were discovered and were addressed. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,,,, +NB146090,70A302,ALF,2/5/2014,"Resident #1 and Resident #2 reported $1,200 missing from the security drawer in their apartment. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +NB146370,70A302,ALF,3/14/2014,Resident #1 dispensed his/her medications until 12/27/13. At that time the facility took over dispensing his/her medications. The facility did not verify medications orders at that time. Resident #1 did not receive one of his/her medications for over two months. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB147053,70A302,ALF,5/13/2014,Resident #1 reported $200.00 missing from his/her lockbox. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +NB147821,70A302,ALF,7/17/2014,"Due to a computer system error regarding the electronic Medication Administration System, Resident #1 did not receive his/her 10:00 pm routine medication. Due to not receiving his/her medication, Resident #1 was anxious. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +NB152873,70A302,ALF,9/20/2015,The facility failed to administer Resident #1's medication according to physician's order. Resident #1 did not suffer any negative outcome other than sleepiness. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC116430B,70A303,ALF,1/4/2010,The facility failed to document or investigate Resident #1's missing giftcards. The failure is a violation of Oregon Administrative Rules.,1,0,,, +BC116433,70A303,ALF,2/20/2011,"Resident #1 and Resident #2 were observed in a sexual act. Witness testimony and facility documentation revealed Resident #1 did not have the capacity to consent to sexual activity. No documented assessment or Service Plan update was completed after the incident nor was the physician or family notified. The facility failed to assess and intervene resulting in potential for serious harm to Resident #1. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,2500,,,Neglect +BC116480,70A303,ALF,2/3/2011,"RP2 was observed administering medications to residents while impaired resulting in multiple medication errors. The facility failed to provide a safe medication administration system resulting in the potential for harm to all residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +BC116588,70A303,ALF,3/23/2011,A staff member did not show up to work resulting in the delay of residents' medications being administered on time. The facility failed to timely administer medication as ordered resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +BC116594,70A303,ALF,3/14/2011,"The Facilities census increased and as a result residents began experiencing longer wait times when calling upon staff for assistance. Resident #1's care plan indicated he/she required standby assistance from staff while bathing. He/she was left unattended in the shower for approximately 20 minutes when staff were called away to assist other residents, exposing the resident to potential harm.",2,0,,, +BC116641,70A303,ALF,1/19/2011,"The facility failed to provide a safe environment resulting in the loss of Resident #1's property. Facility failed to document an internal investigation and report the incident to APS or local law enforcement on the February 11, 2011 theft reported to the facility. Wrongdoing was inconclusive on RP2. The failure is a violation of resident rights, is considered financial exploitation and considered abuse.",2,0,,,Financial abuse +BC117487,70A303,ALF,7/14/2011,The facility failed to provide a safe medication administration system resulting in the resident receiving a double dose of her/his medication. RP2 failed to review the Medication Administration Record prior to administering the medication to Resident #1. There was no visible harm as a result of the error. The failure is a violation of OARs.,2,0,,, +BC121364,70A303,ALF,9/29/2012,"Resident #1 required and was care planned for standby assistance. On or about September 29, 2012, RP2 was assisting Resident #1 with toileting when the resident she/he could not stand anymore. RP2 turned away from Resident #1 to get a wheelchair. Resident #1 subsequently fell and required transporation to the hospital for treatment of a fractured hip. The facility failed to ensure Resident #1's care plan was followed resulting in harm. RP2 was found responsible for neglect of care and constitutes abuse.",3,0,Not Substantiated,Substantiated,Neglect +BC132822,70A303,ALF,2/21/2013,"According to his/her Medication Administration Record, Resident #1 did not receive the prescribed dosage of medication on two separate occasions in the month of February. One of the medications was for pain, causing Resident #1 some discomfort. The facility failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC146693,70A303,ALF,3/28/2014,"The facility failed to follow Resident #1's service plan including bowel management, resulting in constipation requiring digital extractions. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC148300,70A303,ALF,8/24/2014,"Resident #1 had pain medication go missing from his/her room. An unknown individual was found to be responsible for the theft of medication, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Adminstrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH121451A,70A304,ALF,10/9/2012,"The facility had two caregivers scheduled and one medication aide scheduled as routine staffing for the census of 54. On 10/7/12, a caregiver did not come to work. There was only one caregiver and one medication aide between 6am-8am until the replacement caregiver arrived. The facility failed to provide appropriate staffing levels placing all residents at risk for potential harm. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BH121451B,70A304,ALF,10/9/2012,Resident #1's physician ordered treatments for a rash; however he/she did not always receive the correct ointments as ordered. The facility failed to ensure his/her treatment was provided as ordered and failed to maintain a correct Medication Administration Record for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH121637,70A304,ALF,10/2/2012,"On 10/2/2012 at approximately 5:45am, Resident #1 was found outside the facility from an apparent fall and was cold and wet. He/she had no prior attempts to exit the building. The facility failed to check the door alarm when it sounded and staff were unaware that Resident #1 had exited the building. Resident #1 was hospitalized. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH121766,70A304,ALF,11/20/2012,"Resident #1 had a PRN order for a prescription ointment treatment. The facility failed to provide a treatment administration record to document the required components, making it difficult to determine whether or not the treatment was administered. The facility's failure is a violation of Oregon Administrative Rules.",2,0,,, +BH132097,70A304,ALF,1/7/2013,Resident #1 was not treated with dignity and respect by Reported Perpetrator 2. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,,, +BH133464B,70A304,ALF,5/6/2013,"Reported Perpetrator 2 (RP2) accepted an old television from Resident #1. The facility failed to provide a safe environment. RP2 is found responsible for wrongful taking, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +CO14008,70A304,ALF,11/21/2013,"The Facility failed to ensure reports of abuse or suspected abuse were promptly investigated and were reported to the local APD office. The facility failed to investigate Resident #4_x001A_s allegation of Staff 12_x001A_s verbal abuse reported in February 2013. Staff 12 continued to exhibit behaviors that were previously substantiated. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH134275,70A304,ALF,7/6/2012,"The facility failed to investigate Resident #1's fall outside the building on 7/6/2012; failed to conduct an assessment and implement interventions; failed to care plan appropriately for falls; failed to evaluate his/her change of condition and provide an RN assessment. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH146810,70A304,ALF,4/14/2014,"Resident #1 had memory loss, confusion, and had history of wandering in and out of the facility. On 3/10/14, he/she was care planned to be redirected and activities encouraged; however he/she wandering out of the facility on 3/16/14 and 4/14/14 without injury. The facility failed to care plan appropriately for elopements creating a risk of harm. The failures are a violation of Oregon Administrative Rules.",2,,,, +BH145912,70A304,ALF,1/23/2014,Reported Perpetrator 2 (RP2) failed to treat Resident #1 with respect and dignity re: toileting assistance. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH153631,70A304,ALF,9/16/2015,"Reported Perpetrator 2 (RP2) used credit cards belonging to Resident #1, Resident #2 and Resident #3 to purchase merchandise from an online store. RP2's actions are considered theft and constitutes abuse. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +RD105897A,70A305,ALF,11/23/2010,Resident #1's care plan requires a two person transfer at all times due to weakness. RP2 attempted to transfer Resident #1 on her/his own resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +RD116142,70A305,ALF,12/17/2010,RP2 admitted to taking five narcotic pills from Resident #1's room. RP2 was terminated. The facility failed to provide a safe environment resulting in the loss of a resident's medication. RP2 was found substantiated for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +RD117331,70A305,ALF,4/25/2011,"The facility failed to provide a safe environment resulting in the loss of approximately $2,100 from Resident #1 and $144 from Resident #2. Abuse was apportioned to an unknown individual.",3,0,Not Substantiated,Substantiated,Financial abuse +RD132973,70A305,ALF,4/4/2013,"Resident #1 reported money missing from his/her apartment. Resident #1 and witnesses stated he/she always kept the money in the same place and several witnesses saw it the day before it went missing. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking Resident #1's money, which is considered Financial Exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BO164554,70A305,ALF,1/5/2016,The facility failed to adequately monitor Resident #1 and Resident #2. Resident #1 had a history of inappropriate sexual behavior and was able to kiss Resident #2. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES116743,70A306,ALF,4/9/2011,Resident #1 and Resident #2 got into a verbal altercation. Resident #2 fell back during the argument and sustained a minor injury. Resident #2 had a history of being aggressive towards others. The facility failed to provide a safe environment resulting in a negative behavior affecting another resident.,2,0,,, +ES117578,70A306,ALF,7/23/2011,Resident #2 had a history of altercations with other residents. The facility failed to address Resident #2's ongoing behaviors resulting in negative behavior affecting other residents. The failure is a violation of OARs.,2,0,,, +ES129212,70A306,ALF,12/12/2011,"Resident #1 returned from a hospital visit to find approximately $40.00 missing from her/his purse and contents inside the purse were scattered. Investigative findings revealed that the facility failed to provide Resident #1 with a key to her/his lockbox. The facility failed to provide a safe environment resulting in the loss of money from Resident #1. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. Both the facility and unknown individual were found responsible for abuse.",2,0,Substantiated,Substantiated,Financial abuse +ES129521,70A306,ALF,1/27/2012,An oxygen meter was reported missing from Resident #1's room. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown person was held responsible for financial exploitation.,2,0,Not Substantiated,Substantiated,Financial abuse +ES129735,70A306,ALF,4/9/2012,Resident #1 left an envelope with money on her/his door for the newspaper carrier and it was later discovered that the newspaper carrier never received the money. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown individual was found substantiated for financial exploitation.,2,0,Not Substantiated,Substantiated,Neglect +ES120506B,70A306,ALF,7/8/2012,Resident #1 was a new resident to the facility with transfer orders to have blood work completed on a daily basis due to her/his condition. Facility staff missed the transfer order and the resident did not received blood checks for two days. There was no harm as a result of the incident. The facility failed to ensure a physician order. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES120567,70A306,ALF,7/15/2012,"Resident #1's wedding ring was discovered missing on or about July 15, 2012. Internal investigation was initiated, however no known suspects were identified. The facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for the missing ring, is considered financial exploitation and constitutes abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +ES132124,70A306,ALF,12/29/2012,Resident #1 reported $200.00 missing from his/her apartment. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment resulting in the loss of Resident #1_x001A_s money. The facility also failed to complete a full investigation or report the incident to Adult Protective Services. The failures are a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES132435,70A306,ALF,2/13/2013,Resident #1 reported $500 missing from an envelope on the side of his/her chair. Resident #1 also reported an additional $50 missing from his/her wallet. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment resulting in the loss of Resident #1's money. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES120625,70A306,ALF,7/23/2012,Resident #1 reported $160.00 missing from a container in his/her apartment. Resident #2 reported $60.00 missing from the locking cabinet in his/her apartment. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment resulting in the loss of Resident #1 and #2_x001A_s money. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES133297,70A306,ALF,5/23/2013,"It was reported Residents #1 and #2 had to wait for long periods of time after pulling their call lights for assistance, resulting in incontinence. Witnesses stated they had a problem with the call system for approximately a week and a half. The facility said they were ""looking into getting the system repaired."" The facility failed to answer call lights in a timely manner. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES134765,70A306,ALF,10/11/2013,"Resident #1 discovered $145 missing from her/his wallet. There was no locking drawer in the resident's room to keep her/his belongings safe. The facility failed to provide a locking drawer resulting in the loss of resident money. The failure is a violation of resident rights, is considered neglect of care resulting in finanical exploitation and constitutes abuse. An unknown individual was also held responsible for financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +ES132104,70A306,ALF,12/26/2012,The facility failed to order a prescription resulting in the resident not receiving the medication for 12 days. There was no negative outcome as a result of the error. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES132102,70A306,ALF,1/6/2013,"Resident #2 had a history of aggressive behaviors towards others. The facility failed to address Resident #2's behaviors resulting in negative outcome to residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES146552,70A306,ALF,3/27/2014,"Complainant reported that the facility did not answer Resident #1's call light promptly and left the resident alone after 911 was called. Witness testimony and facility documentation confirmed that it took over 30 minutes for Resident #1's call light to be answered. Resident #1 was also left unattended after 911 was called. The facility failed to answer the call light in a timely manner. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES148044,70A306,ALF,8/5/2014,"Resident #1 did not like others to enter her/his room had a history of altercations with other residents. Resident #2 had a history of entering resident's rooms. On or about August 5, 2014, Resident #1 and Resident #2 engaged in an altercation when Resident #2 attempted to enter Resident #1's room. The facility failed to adequately address residents' behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES147883,70A306,ALF,5/5/2014,"Resident #1 reported an electronic notebook taken from her/his locked room. The facility failed to ensure a safe environment. The facility also failed document that an investigation was conducted. The failures are violations of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +ES147884,70A306,ALF,7/21/2014,"Resident #1 reported an electronic notebook taken from her/his locked room. The facility failed to ensure a safe environment. The facility also failed document that an investigation was conducted. The failures are violations of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +ES148328,70A306,ALF,8/29/2014,"Resident #1 reported $200 cash missing from a bag located in her/his room. There have been multiple recent thefts at the facility and no changes have been made to address it. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",3,400,Not Substantiated,Substantiated,Financial abuse +ES148198B,70A306,ALF,8/13/2014,"Resident #2's wallet and money was taken and secured in the facility's medication room after the resident was transported to the hospital. Resident #2 discovered approximately $45 missing when the wallet was returned. The facility failed to ensure a safe environment resulting in the loss of resident property. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. An unknown person was also found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +ES148396,70A306,ALF,8/30/2014,"Resident #1 reported $45 cash missing from a wallet located in her/his room. There have been multiple recent thefts at the facility with a lack of adequate changes to address it. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,250,Not Substantiated,Substantiated,Financial abuse +ES148576,70A306,ALF,9/14/2014,"Resident #1 discovered money missing from a purse located in her/his room. The investigation was unable to identify any suspects. The facility failed to ensure a safe environment resulting in the loss of Resident #1's money. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES147687,70A306,ALF,7/6/2014,"Resident #1 and Resident #2 both reported missing items from their respective rooms including cash, a camera and two rings. There have been multiple recent thefts in the facility and local law enforcement has been notified. The facility failed to ensure a safe enviromnent and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +ES149180,70A306,ALF,11/6/2014,"Resident #1 was observed slapping Resident #2 in the dining room. Resident #1 had a history of aggressive and disruptive behaviors towards residents and staff. Resident #1's care plan directed staff to redirect when Resident #1 is upset. There were no additional interventions. The facility failed to appropriately care plan Resident #1's behaviors resulting in continued negative behaviors affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes.",2,,,,Neglect +ES148902,70A306,ALF,10/11/2014,Resident #1's was not properly transferred resulting in a small skin abrasion and is a violation of Oregon Administrative Rules.,2,,,, +ES146151,70A306,ALF,2/20/2014,"Resident #1's locking drawer was tampered with and $1,200 cash was discovered missing. Local law enforcement was notified and an internal investigation was initiated, however no suspects were identified. The facility failed to ensure a safe environment resulting in the loss of resident property. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +ES150544,70A306,ALF,11/9/2014,"Resident #1 has a condition related to cognition and had recently been observed to touch other residents of the opposite gender. There was no care planning to address the behavior. On November 9, 2014, Resident #1 inappropriately touched Resident #2's breast without consent in Resident #2's room. Resident #2 experienced anxiety and fear after the incident. The facility failed to adequately care plan Resident #1's behavior resulting in harm to Resident #2. The failure is a violation of resident rights, and is considered neglect of care resulting in sexual abuse.",3,300,,,Neglect +ES150916,70A306,ALF,9/30/2014,"RP2 took money collected by residents' intended to be donated to a non profit organization. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse. The facility failed to ensure a safe environment and is a violation of resident rights.",2,,Not Substantiated,Substantiated,Financial abuse +ES159773,70A306,ALF,1/1/2015,The facility failed to ensure Resident #1 was transferred as care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES152732,70A306,ALF,7/31/2015,"Resident #1 reported consuming the wrong medication. Facility documentation did not show an incident related to Resident #1 getting the wrong medication however, staff were aware of the situation. The facility failed to appropriately document the incident and is a violation of Oregon Administrative Rules.",2,,,, +ES103941,70A307,ALF,3/30/2010,"A resident of the Facility experienced a loss of his/her personal property from his/her room within the Facility. Upon being informed of the missing property, the Facility failed to perform an internal investigation or contact law enforcement to establish a report.",2,0,,,Financial abuse +ES105464A,70A307,ALF,9/2/2010,A resident of the Facility reported that he/she was missing money from his/her room. Upon observation it was determined that his/her locking file cabinet had been pried open. The Facility was not able to establish any suspects in the loss of the resident's money.,2,0,,,Financial abuse +ES105464B,70A307,ALF,9/2/2010,"A resident of the Facility discovered that his/her locking drawer in his/her room had been tampered with. Upon looking inside, the resident found that a bubble pack of medication was missing. The Facility was not able to conclusively determine who was responsible for the theft of medication.",2,0,,,Financial abuse +ES118157,70A307,ALF,9/20/2011,"Pain medications were reported missing for Resident #1, Resident #2 and Resident #3. Reported Perpetrator 2 (RP2), Reported Perpetrator 3 (RP3), and Reported Perpetrator 4 (RP4) denied taking the pain medications. An unknown individual is responsible for financial exploitation by theft of mediations. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +ES129047A,70A307,ALF,1/20/2012,"Reported Perpetrator 2 (RP2) took photos of Resident #1, Resident #2 and Resident #3 without their permission. The unauthorized photos were then uploaded to an online photo sharing site. RP2's actions are a violation of resident rights and constitutes emotional abuse. The facility failed to provide a safe environment. The failure is a violation Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +ES129047B,70A307,ALF,1/20/2012,Reported Perpetrator 2 (RP2) took photographs of Resident #1 naked in the shower without their permission. The unauthorized photos were then uploaded to an online photo sharing site. RP2's actions are a violation of resident rights and constitutes emotional abuse. The facility failed to provide a safe environment. The failure is a violation Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +ES134843,70A307,ALF,10/21/2013,"Resident #1 reported money and items missing from his/her room. An unknown individual was responsible for the theft of Resident #1_x001A_s items and money, which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES145612,70A307,ALF,1/6/2014,It was discovered that thirty narcotic medications belonging to Resident #1 were missing from the medication room. Reported Perpetrator 2 (RP2) was observed on video surveillance taking the bubble pack of narcotics and the narcotic sheet from the medication room. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MM105920,70A308,ALF,12/1/2010,"RP2 administered Resident #1 the wrong dose and medication. Resident #1 fell out of bed and suffered bruising, pain and contusion to shoulder and thigh. The facility failed to provide a safe medication administration system resulting in minor harm to Resident #1.",2,0,Substantiated,Substantiated,Neglect +MM116192A,70A308,ALF,12/12/2010,"RP2 forcefully grabbed Resident #1 by the hands, causing a skin tear that required several stitches. RP2 had a history of being inappropriate with residents while providing care, with facility knowledge, and has been allowed to continue to work with residents. The facility failed to protect Resident #1 from rough treatment. The failure is a violation of resident rights, is considered physical abuse and constitutes abuse.",2,0,Substantiated,Substantiated,Physical Abuse +MM116192B,70A308,ALF,12/12/2010,Failed to ensure Resident #1's medications were administered as ordered resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +DA116804,70A308,ALF,4/1/2011,"The facility failed to addresses Resident #2's behavior resulting in continued negative behavior towards other residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117030,70A308,ALF,5/13/2011,RP2 became frustrated and hit Resident #1 while providing care. Staff heard yelling between RP2 and Resident #1. The facility failed to provide a safe environment resulting in minor harm to Resident #1. Abuse was apportioned to RP2.,2,0,Not Substantiated,Substantiated,Physical Abuse +MM117133,70A308,ALF,5/27/2011,"Resident #1 exhibited aggressive behavior towards staff and residents. The facility failed to address Resident #1's aggressive behavior resulting in negative behavior affecting other residents. The failure is a violation of resident rights, is considered neglect of care and constitues abuse.",2,0,,,Neglect +MM128986,70A308,ALF,12/23/2011,"Resident #1 experienced increased wandering and exit seeking behaviors. The facility failed to adequately care plan resulting in Resident #1 wandering from the facility on at least five known occasions. The facility_x001A_s failure put Resident #1 at risk for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM129304,70A308,ALF,1/11/2012,"On January 11, 2012, physician ordered Resident #1 to receive a specific medication after test showed INR levels were critically high. Resident #1 did not receive the medication and INR levels remained high. Resident #1 was subsequently sent to the hospital on January 13, 2012. The facility failed to follow physician's orders creating a risk of serious harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +MM120523,70A308,ALF,5/30/2012,"Resident #1 had a history of physical and verbal aggressive behavior towards Resident #2. Resident #1 also had a history of aggressive behavior towards staff when trying to assist Resident #2 with care needs. The facility failed to appropriately monitor and update residents' care plans to prevent future incidents. Resident #1's aggressive behavior continued resulting in harm to Resident #2 and placed risk of harm to others. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MM121944,70A308,ALF,12/13/2012,"The facility failed to administer Resident #1_x001A_s routine pain medication as ordered resulting in pain on two known occasions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM132211,70A308,ALF,1/19/2013,"Resident #1's care plan directed only hospice or facility RN to provide wound care for first and second degree burns on her/his arm. On or about January 24, 2013, Resident #1's bandage was observed to be too tight that resulted in an open wound. It was discovered that someone other than the hospice or facility RN provided wound care. The facility failed to ensure the care plan was followed as directed. The failure is a violation of resident rights, is considered negelct of care and constitutes abuse.",2,0,,,Neglect +MM132637,70A308,ALF,2/25/2013,"Resident #1, Resident #2 and Resident #3 did not receive medications as prescribed. Resident #1 experienced nausea, dizziness and chills from medications not being administered timely. Resident call lights are not being responded to in a timely manner. The facility failed to provide a safe environment for residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,, +MM132732,70A308,ALF,3/22/2013,Resident #2 was administered an incorrect amount of Morphine resulting in him/her receiving too much of the medication. An order reducing the amount was charted by the facility but they failed to cancel the old order and were administering both orders. Call lights are not being answered in a timely manner and medications are being given late. The facility failed to provide a safe medication administration system. The failures are a violation Oregon Administrative Rules.,2,0,,, +MM132095A,70A308,ALF,1/9/2013,Resident #1 was moved to a new room after he/she went from private pay to Medicaid. Resident #1 was told that the moving company would set his/her new room up. The room was not set up when Resident #1 moved in. His/her belongings were stacked everywhere. Resident #1 fell and was transported to the hospital. Resident #1 sustained bruises. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MM133338,70A308,ALF,5/25/2013,"Resident #1 was care planned to assist with feedings. On May 27, 2013, two untouched food trays were in Resident #1 room. The facility failed to follow Resident #1's service plan. On a separate occasion, Resident #1 was observed being changed by two staff with the door open to the hallway. The facility failed to treat Resident #1 with dignity and respect. The failures are violations of Oregon Administrative Rules.",2,,,, +MM133456,70A308,ALF,5/22/2013,Resident #1 had bruising on legs believed to have been a result of staff rubbing lotion on skin. The facility failed to report incident and failed to conduct a thorough investigation. The failure is a violation Oregon Administrative Rules.,2,,,, +MM133298,70A308,ALF,5/17/2013,Condition issued effective 9/19/13. Please see Condition ALFCD13-005 for specific details.,3,0,,,Neglect +MM133457,70A308,ALF,5/22/2013,"Complainant reported residents were being intimidated by staff for making complaints. Witness testimony revealed residents were not being treated with respect and dignity. The facility failed to ensure Residents' #1, #2 and #3 were treated with respect and dignity resulting in the loss of dignity. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM133884,70A308,ALF,7/12/2013,"Resident #1 required assistance with dressing in the mornings and evenings. On one known occassions, Resident #1 was not provided with evening assistance. The facility failed to follow Resident #1's care plan.",2,,,, +MM132121,70A308,ALF,12/20/2012,"Resident #1 had an order for a narcotic medication patch to be administered every 72 hours. On the evening of December 20, 2012, it was discovered that the pain patch was not administered as ordered after Resident #1 was observed to be in pain and required additional pain medication. The facility failed to ensure medication was administered as ordered resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM135189,70A308,ALF,11/15/2013,"Resident #1 fell in the early morning, resulting in a black eye and bruising. According to witnesses, it took facility staff some time to respond. Witness #1 had to retrieve staff to alert them to the situation. It was facility protocol to answer call lights within 5 minutes. The facility failed to respond in a timely manner. The failure is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM121381,70A308,ALF,10/15/2012,"Complainant reported medications were found in Resident #1's room, she/he had not had a shower in a couple of weeks and was observed to not eat meals. Facility documentation revealed no progress notes between September 15, 2012 and October 14, 2012. Resident #1 was placed on Hospice October 21st and the service plan was updated to address the change in care needs. The facility failed to provide oversight and monitoring of a change of condition resulting in poor continuity of care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM148424,70A308,ALF,9/1/2014,"The facility failed to maintain a safe medication administration system. Resident #1 was given another residents medication, and was sent to the hospital for observation. This failure is neglect of care, which is considered abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MM147556A,70A308,ALF,5/27/2014,"Resident #1 had medication taken from his/her locked drawer. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1 from theft, and failed to report the potential abuse. These failures are violations of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM148740,70A308,ALF,9/17/2014,"The facility failed to provide appropriate transfer assistance to Resident #1. Care staff were helping Resident #1 with toileting care and Resident #1 expressed he/she had tired legs. Care staff attempted to finish toileting care and Resident #1 had to remain standing. Resident #1 fell and suffered a lower extremity fracture. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM150522,70A308,ALF,3/4/2015,The facility failed to bandage Resident #1's injury as specified in Resident #1's doctor's order. This failure is a violation of Oregon Administrative Rules.,2,,,, +MM150820,70A308,ALF,3/27/2015,"Resident #1 had medication go missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM150695,70A308,ALF,3/14/2015,"Resident #1 had medication, and Resident #2 had money go missing from his/her room. The medication and money was taken by Reported Perpetrator #2 (RP2) and RP2 is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM151727,70A308,ALF,6/21/2015,"Resident #1 had medication go missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM151932,70A308,ALF,7/2/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,200,Not Substantiated,Substantiated, +MM152285,70A308,ALF,6/15/2015,"Resident #1 suffered an injury fall while being transported in a facility vehicle. The facility failed to ensure a safe environment resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC116375,70A309,ALF,2/16/2011,It was determined that Facility staff was failing to follow the resident's care plan with respect to using a gait belt when assisting the resident with all transfers. The resident presented with bruising to which he/she could not recall how it occurred. It was unclear if the resident's bruising came from inappropriate transferring or as a result of contacting something in his/her environment.,2,0,,, +MM133394,70A311,ALF,5/31/2013,Reported Perpetrator 2 (RP2) took a video of Resident #1 without his/her permission. The facility failed to assure Resident #1_x001A_s rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM133663,70A311,ALF,6/26/2013,Twelve pills were missing from Resident #1_x001A_s discontinued narcotic card. Reported Perpetrator 2 (RP2) admitted taking the pills. RP2 was found responsible for theft of narcotics which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MM133969,70A311,ALF,7/18/2013,"Resident #1 was witness to a verbal argument involving Reported Perpetrator 2, Reported Perpetrator 3 and Reported Perpetrator 4 regarding transport for appointments. This argument caused Resident #1 emotional distress. The facility failed to assure Resident #1_x001A_s rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV148801,70A311,ALF,8/15/2014,"Resident #1 was prescribed a medication to be administered four times per day. On three occasions, it was found that the medication was replaced with another medication. Resident #1 experienced no negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM148858,70A311,ALF,10/8/2014,"Resident #1 had increased dementia resulting in incontinency issues. His/her increased toileting needs were not being met by the facility. The facility failed to provide appropriate incontinence care to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +OR0001001200,70A311,ALF,9/9/2015,,1,,,Substantiated, +OR0001001201,70A311,ALF,9/9/2015,,1,,,Substantiated, +HB121352,70A312,ALF,10/15/2012,"Resident #1 had a physician's order for a narcotic pain patch to be administered every 48 hours. Resident #1 did not received two consecutive pain patches, a total of 4 days as scheduled resulting in pain symptoms associated with withdrawal. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB132851,70A312,ALF,4/5/2013,"Home Health visited Resident #1 on December 27, 2012, and Resident #1 was not verbally responding. He/she was transported to the hospital. Resident #1 had an infected toe. The infected toe was the source of a blood infection. Resident #1's family and physician were not notified of Resident #1 refusing care. The facility failed to assess Resident #1 for a change of condition and obtain timely medical treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB146711,70A312,ALF,4/11/2014,Reported Perpetrator 2 (RP2) took a photo of Resident #1 nude while toileting without his/her permission. The unauthorized photo was then sent out on a public media sight. RP2's actions are a significant violation of resident rights and constitute sexual abuse. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Sexual abuse +HB148442,70A312,ALF,9/9/2014,"Resident #1 reported a gold ring, necklace and $3,000 was missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC118525,70A314,ALF,11/19/2011,RP2 failed to document administration of morning medication resulting in Resident #1 receiving a double dose. RP2 also failed to check Resident #1's CBGs at noon as required. Resident #1 was monitored for 72 hours with no negative outcome.,2,0,,, +BC129327,70A314,ALF,2/18/2012,"Resident #1 had a negative reaction to a new prescribed medication. He/she had new physician ordered medications reflecting new and discontinued medications on 2/17/12. A new Medication Administration Record (MAR) was created; however the old MAR was not properly documented to reflect the discontinued medications. Resident #1 was administered a discontinued medication on 2/18/12 in error. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC120791,70A314,ALF,7/18/2012,Resident #1 did not receive his/her medications as ordered by his/her physician for approximately five days; however he/she did not have an observable negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121052,70A314,ALF,8/20/2012,"Resident #1 was not administered his/her 8am medication until 11am, resulting in dizziness experienced by him/her at 10:30am. The facility failed to maintain a safe medication administration and failed to maintain staffing levels to provide medication administration timely as prescribed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,250,,,Neglect +BC121056,70A314,ALF,8/20/2012,"On 8/24/12, Resident #1 was not administered his/her ordered medication by responsibility of Reported Perpetrator 2. Resident #1 had no negative outcome. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,0,,, +BC121459,70A314,ALF,5/5/2012,"The facility failed to investigate, report to APS, and maintain a safe medication administration system. An audit completed discovered approximately 135 incidents in which residents did not receive medications or their medications were not correctly recorded on the Medication Administration Records. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC120340,70A314,ALF,6/18/2012,"The facility failed to maintain a safe medication administration system which resulted in multiple errors on 9 narcotic reporting sheets for seven residents; one narcotic recording sheet containing a forged signature of a licensed staff person; and Resident #1_x001A_s entire card of a recent medication with 30 pills was missing. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC121935,70A314,ALF,12/16/2012,Resident #1 was not administered his/her medications as ordered. He/she was monitored and had no ill effects. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +BC133856,70A314,ALF,7/4/2013,"The Facility failed to provide adequate professional oversight of the medication administration system to ensure medications were safely administered to Resident #1. Resident #1 was administered a significant increase of medication resulting in potential for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC146362,70A314,ALF,3/4/2014,"Resident #1 was care planned for moderate to maximum assistance with toileting, and standby and contact guard assistance with mobility and transfers. Reported Perpetrator #2 (RP2) left Resident #1 unattended on the toilet and Resident #1 sustained an un-witnessed fall with no injuries. The facility failed to ensure RP2 followed Resident #1's care plan for toileting assistance. This failure is a violation of resident rights, and Oregon Administrative Rules.",2,,,, +BC147850,70A314,ALF,7/14/2014,"Reported Perpetrator 2 (RP2) took slot machine tickets from Resident #1 and cashed them at the establishment, which is considered financial exploitation and constitutes abuse. RP2 is found responsible for abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +CO14223,70A314,ALF,10/2/2014,"The facility failed to ensure reasonable precautions were taken against conditions that could threaten the health, safety and welfare of residents. Resident #9 was at high risk for elopement, and verbally and physically threatened other residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC148970,70A314,ALF,7/29/2014,"Resident #1's gold necklace and approximately $125 went missing from his/her room. An unknown individual was determined responsible for the theft of his/her property, which constitutes abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BC164764,70A314,ALF,2/21/2016,"The facility failed to maintain a safe medication administration system and failed to ensure qualified staff administered medications. Reported Perpetrator 2 (RP2) administered an incorrect dosage of medication to Resident #1, resulting in a serious overdose. RP2_x001A_s actions are considered neglect of care, which constitutes abuse. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,2500,Substantiated,Substantiated,Neglect +BC116447B,70A315,ALF,3/1/2011,"When Resident #2 was sent out of the Facility due to behaviors, the Facility was not able to meet the care needs of his/her roommate, Resident #1. Resident #1 and Resident #2 were admitted at the same time, but the Facility did not staff accordingly or have the ability to meet Resident #1_x001A_s care needs following admission.",1,0,,, +BC135514,70A315,ALF,12/24/2013,"Resident #1 did not receive his/her narcotic pain patch medication as ordered and was transported to the hospital for treatment, suffering from severe withdrawal symptoms. The facility failed to ensure a safe medication administration system. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC153383,70A315,ALF,10/25/2015,The facility failed to adequately administer a safe medication administration system. Resident #1 was accidently given the wrong medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +GB105982,70A316,ALF,12/10/2010,"Complainant reported RP2 put finger in Resident #1's rectum while showering her/him. Resident #1 stated she/he knew it was an accident and RP2 was not aware of the incident until later when she/he was talked to. The investigation concluded the facility failed to assure resident rights, resulting in the loss of dignity. The failure is a violation of OARs.",2,0,,, +GB105824,70A316,ALF,11/24/2010,Staff did not count medications after receiving them as required. It is unable to be determined if and when the medications went missing. The facility failed to ensure a safe medication administration system and is a failure of Oregon Administrative Rules.,2,0,,, +CO11048,70A316,ALF,3/23/2011,"The facility failed to ensure significant changes of condition were evaluated, monitored, interventions developed, assessed by the RN and findings documented for four residents (#s 1, 2, 3 & 4) who experienced significant changes of condition related to weight gain/loss. Resident #1 experienced severe weight gain of 33% (or 72 lbs) in 6 months; Resident #2 experienced a severe weight loss of 7.9% (or 11 lbs) in one month; Resident #3 experienced a severe weight loss of 12.7% (or 22 lbs) in one month; and Resident #4 experienced 6.3% (or 14 lbs) in one month. The facility also failed to administer medications as ordered by the physician resulting in Resident #2 experiencing unrelieved pain for three days. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,750,,,Neglect +GB116617,70A316,ALF,3/7/2011,The facility failed to conduct an internal investigation after Resident #1 indicated that RP2 inappropriately touched her/him. The facility also failed to assure resident rights resulting in the loss of dignity when RP2 confronted Resident #1 about the accusations. Two staff are now required to care for Resident #1. The failures are violation of OARs.,2,0,,, +GB117144,70A316,ALF,12/26/2010,"The facility failed to follow physician medication and treatment orders. Resident #1 experienced pain during the 24 hours that medication was unavailable. The facility did not remove Resident #1's leg boot for over a month despite order to remove for hygiene because the order was not written on the treatment record. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +GB129225,70A316,ALF,2/9/2012,"RP2 worked as a medication aide at the facility and was discovered with several narcotic prescriptions belonging to multiple residents in her/his vehicle by local law enforcement. RP2 was previously suspected of theft of narcotic medications on or about November 2011. The facility failed to provide a safe medication administration system resulting in the theft of several narcotic medications from multiple residents. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +GB133508,70A316,ALF,6/15/2013,"Complainant reported approximately 60 prescribed medications from Resident #1's room. Investigation was unable to determine who took the medications. The facility failed to provide a safe environment resulting in the loss of medication. An unknown person was held responsible for the theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +GB135015,70A316,ALF,11/8/2013,"Resident #1 reported theft of jewelry from her/his room to facility staff. Facility failed to report the suspected theft or conduct an internal investigation. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +GB146038,70A316,ALF,2/7/2014,"Resident #1 had narcotic pain medication stolen from his/her room. Reported Perpetrator #2 was found responsible for the theft, which is considered financial abuse. The facility failed to protect Resident #1's property from theft. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +GB146266,70A316,ALF,3/5/2014,"Resident #1 had a standing order for a specific medication and able to self-administer her/his own medications. The facility held Resident #1's medication without consent. The facility failed to ensure Resident #1 was treated with dignity and respect. Resident #2 had an order for medication related to iron deficiency. The MAR (Medication Administration Record) revealed no order for iron and test revealed Resident #2 had a severely deficient iron level. The facility failed to ensure an accurate MAR resulting in harm. The facility also failed to timely pick up and administer an ordered antibiotic for Resident #2 resulting in the delay in administration. The facility failed to provide a safe medication administration system. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +GB150302,70A316,ALF,1/14/2015,Resident #1 had an order for applying lotion and boot on a nightly basis. The facility failed to appropariately document and follow treatment orders as prescribed. The failures are violations of Oregon Administrative rules and is a potential for harm.,2,,,, +GB150783,70A316,ALF,4/1/2015,"The facility failed to ensure a safe environment resulting in the loss of money from two residents. The failure was a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +GB150703A,70A316,ALF,2/10/2015,"Resident #1 reported missing narcotic medication from her/his room. RP2 was suspected, however investigation was unable to determine who took them. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +GB150703B,70A316,ALF,2/10/2015,"Resident #2 reported missing narcotic medication from her/his room. RP2 was suspected and during the course of the investigation it was revealed that RP2 had requested and received narcotic medication from Resident #2. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +GB151443,70A316,ALF,6/1/2015,"Complainant reported missing money from Resident #1's PIF (Personal Incidental Fund) account. Upon an audit, it was discovered that other residents were also missing money. RP2 was suspected, however it was unable to be determined who took the residents' money. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +CO13016,70A319,ALF,1/16/2013,"The facility failed to ensure an evaluation was reflective of Resident #2_x001A_s health status; failed to evaluate a change of condition, develop interventions or monitor his/her significant change of condition; and failed to ensure his/her significant change of condition was assessed by a Registered Nurse. Resident #2 suffered a severe weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH132069,70A319,ALF,11/11/2012,"Resident #1 administered his/her own medications and facility provided a cabinet to lock the medication in his/her apartment. Resident #1 admitted to not locking the medication in the cabinet, but stated he/she always locked the front door. Approximately 5 pain patches and approximately 50 pain pills were reported missing on 11/9/12. An unknown person is responsible for the theft of Resident #1's medications. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +BH134999,70A319,ALF,10/11/2013,"Physician orders were obtained for the facility to manage Resident #1_x001A_s medications, a change from the self-medication status, after discovering several loose pills of medications were found in his/her cupboards. The facility began administering the medications as ordered; however failed to remove the loose pills from Resident #1_x001A_s room. The facility failed to take reasonable precautions to provide a safe environment, exposing Resident #1 to potential harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +BH146282,70A319,ALF,3/4/2014,"On 3/14/14, Resident #1 discovered about $1700 missing from his/her locked drawer in his/her bedroom. The facility investigation revealed that the key used for the locked drawer was not unique and it was possible another staff person was able to access the locked drawer using another key. An unknown individual is responsible for the theft of Resident #1's money. The Facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +CO13041,70A320,ALF,4/4/2013,"The facility failed to provide effective administrative oversight regarding residents' quality of care and services as evidenced by the initial licensure survey findings completed on April 4, 2013.",3,0,,,Neglect +MV133039B,70A320,ALF,3/21/2013,The facility failed to obtain physician's orders for Resident #1's medications. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV133218,70A320,ALF,5/1/2013,Resident #1 did not receive two new ordered medications for approximately nine (9) days. He/she was also administered a medication for approximately seven (7) days after it had been discontinued. Resident #1 had no observable ill effects. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,,,, +MV134522,70A320,ALF,9/21/2013,"Resident #1 did not receive his/her scheduled dose of medication on 9/21/13 and 9/22/13 resulting in shortness of breath and transportation to hospital for treatment. The Facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV135109,70A320,ALF,10/1/2013,"The facility was aware that Resident #2 had a history of verbally abusing Resident #1; however it was permitted for them to share the same living quarters. Resident #2 had two documented incidents of being aggressive toward Resident #1, resulting in a bruise. The facility failed to take reasonable precautions to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV146754,70A320,ALF,4/9/2014,"Resident #1 reported missing money out of his/her wallet. There was another theft of another resident at the same day/shift and was speculated that RP2 was the suspect, but unable to determine. An unknown individual is responsible for the theft of his/her money, which constitutes financial exploitation. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV146755,70A320,ALF,4/9/2014,Resident #1's credit card was stolen out of his/her room. The credit card was used in three locations and Reported Perpetrator 2 (RP2) was on surveillance at one location using Resident #1's credit card. RP2 is found responsible for the theft and use of Resident #1's credit card which constitutes financial exploitation. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Financial abuse +MV121298,70A320,ALF,9/23/2012,The facility failed to ensure services were provided to Resident #1 and failed to ensure effective communication methods among staff. The failures are a violation of resident rights and Oregon Administrative Rules.,2,,,, +MV147397,70A320,ALF,6/10/2014,"Resident #1 was known to forget to come to meals so he/she was care planned to be escorted to meals. On 6/10/14, Resident #1 walked out of the facility before lunch and wasn_x001A_t noticed missing until dinner. He/she was not escorted to lunch that day and the resident meal log was not filled out. Resident #1 had fallen into blackberry bushes, was found by law enforcement around 8:20pm, and taken to the hospital. The facility failed to follow Resident #1_x001A_s care plan to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV147670,70A320,ALF,7/5/2014,The facility failed to provide medication and obtain clarification of an order for Resident #1. He/she went without medication for approximately five days; however no noted discomfort. The facility failed to maintain a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,,,, +MV147789,70A320,ALF,4/22/2014,"Reported Perpetrator 2 (RP2) began providing catheter care to Resident #1 as required in his/her care plan but could not complete the task. Resident #1 stood up and inadvertently pulled the catheter out causing bleeding and swelling. RP2's actions were neglectful in care, which constitutes abuse. The facility failed to ensure Resident #1's care plan was followed which is violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +MV152582,70A320,ALF,8/12/2015,"Resident #1 reported money missing from his/her wallet. The investigation was unable to determine a named suspect; therefore an unknown individual is found responsible for the theft of money, which constitutes abuse. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA146128,70A321,ALF,2/16/2014,"Resident #1's medication went missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA146199,70A321,ALF,2/22/2014,"Resident #1 entered Resident #2's room without permission and assaulted Resident #2. Resident #1 had a history of wandering, but has never injured another person. Resident #2 sustained a bruise and a sore shoulder. The facility failed to address Resident #1's behaviors. The failure is a violation of Oregon administrative Rules.",2,,,, +DA146832,70A321,ALF,4/18/2014,"Resident #1 had $200 go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA148628,70A321,ALF,9/9/2014,"Resident #1 had medication go missing. The medication was taken by an Reported Perpetrator #2 whom is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +EN134855,70A322,ALF,7/2/2013,"Resident #1 missed two dosages of a medication because the facility did not have the medication available. Although Resident #1 did not experience any negative health consequences, the potential risk of missing an ordered medication remained. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +EN146653,70A322,ALF,3/20/2014,Resident #1 had a physician order for wound dressing changed twice per day. The facility failed to change his/her wound dressing as scheduled on three occasions. This failure is a violation of Oregon Administrative Rules.,2,,,, +EN134267,70A322,ALF,7/12/2013,"Resident #1 was found on the floor next to his/her bed. His/her bed was left in the highest position, the floor mat alarm was turned off and Resident #1 was not checked at the appropriate time. He/she was transported to the hospital to be checked. No fractures were found. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.",2,,,, +EN148285,70A322,ALF,7/29/2014,"Resident #1 was placed in bed for a nap and his/her oxygen was not transferred and turned on. While doing safety checks a staff member discovered the oxygen was not on. Resident #1 experienced chest pain and shortness of breath. The facility failed to follow Resident #1's service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +EN147996,70A322,ALF,5/12/2014,"Between March 17, 2014 and May 10, 2014, Resident #1 had wait times after calling for assistance from approximately 26 minutes to over an hour and forty minutes. Resident #1 had to wait in wet garments until someone responded. This resulted in Resident #1 developing skin breakdown. On multiple occasions Resident #1's pendant was not reset, therefore, it would not work. The facility failed to respond to Resident #1's calls for assistance in a timely manner and assure call systems were working. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +EN151183,70A322,ALF,2/11/2015,Resident #1 was prescribed thickened liquids by his/her physician. The facility did not implement the order. The facility failed to implement a physician's order for thickened liquids. The failure is a violation of Oregon Administrative Rules.,2,,,, +EN151928,70A322,ALF,5/29/2015,Resident #1 and Resident #2's care plans stated they are on special diets which require low sugar. Both residents were given brown sugar on their oatmeal which elevated their blood sugar. The facility failed to follow the care plans for Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,,,, +EN151929,70A322,ALF,6/15/2015,It was reported that Resident #1's wedding ring was missing. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +EN146340,70A322,ALF,1/16/2014,"Resident #1 had a history of falls and his/her service plan stated his/her wander guard was to be attached at all times. Resident #1 slipped out of his/her wheelchair sustaining an abrasion on his/her back, the wander guard was not attached. The facility failed to follow Resident #1's service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +EN153550,70A322,ALF,8/10/2015,Despite training Reported Perpetrator 2 (RP2) administered Resident #1_x001A_s blood sugar medication into his/her shoulder. Staff were trained to give injections in a fatty area and not administer in places such as the shoulder. Resident #1 experienced pain and bruising. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to assure a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +EN153754,70A322,ALF,10/1/2015,Resident #1 made a sexual comment toward Reported Perpetrator 2 (RP2) and RP2 responded by yelling angrily at Resident #1. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES153534,70A323,ALF,11/9/2015,"Resident #1's pain medication was not available when needed; therefore a delay in administering his/her pain medication. Resident #1 had more pain than usual. The facility failed to have a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES153866,70A323,ALF,12/1/2015,The facility failed to ensure Resident #1 was administered his/her correct medication for approximately 5 days. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +ES153804,70A323,ALF,12/2/2015,"Resident #1 had around $800 - $1,000 in his/her room that came up missing. Reported Perpetrator #2 (RP2) is responsible for the theft of Resident #1's money which constitutes financial exploitation. The facility failed to provide a safe environment which violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +HB151094,70A324,ALF,4/28/2015,Resident #1 reported RP2 was verbally abusive when the resident used the call light multiple times to request assistance. RP2 was terminated. RP2 was found responsible for verbal abuse. The facility is responsible for the conduct of their staff and is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RB132453,70M001,ALF,2/15/2013,"The facility failed to follow Resident #1's care plan and provide service regarding ambulation and transfer assistance. Resident #1 experienced falls resulting in complaints of pain. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +RB134008B,70M001,ALF,7/24/2013,"Resident #2 fell four times between April and July 2013, resulting in injuries on three of those occasions. A Managed Risk Assessment and Plan was not put into place until mid-June. Resident #2's Service Plan does not address his/her mobility status or needs. The facility failed to properly plan care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB134008A,70M001,ALF,7/24/2013,"Resident #1 had a fever daily between 06/12/13 and 06/17/13 and was given fever-reducing medication to control it. There was no documentation of Resident #1's physician being notified of the continuous fever. Resident #1 was transported to the hospital on 06/17/13 and was diagnosed and treated for an infection. The facility failed to assure timely medical treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS118215,70M002,ALF,10/13/2011,"Resident #1 was prescribed a medication to be given daily. Due to inaccurate Medical Administration Record (MAR) documentation, Resident #1 did not receive h/h prescribed medication on three individual dates.",2,0,,, +MS129369,70M002,ALF,2/29/2012,Resident #1 reported $200.00 missing from his/her apartment. An unknown individual was found responsible for financial exploitation. The facility failed to provide a safe environment resulting in the loss of Resident #1's money. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated, +MS129705,70M002,ALF,3/12/2012,Resident #1 reported money missing from his/her wallet on two occasions. An unknown individual was determined to be responsible for the theft of money. The facility failed to provide a safe environment for resident #1 resulting in loss of money. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MS129660,70M002,ALF,3/31/2012,Resident #1 reported $150.00 to $250.00 missing from his/her bag in his/her apartment. An unknown individual was held responsible for financial exploitation which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,250,,, +MS120242,70M002,ALF,6/8/2012,"Resident #1 was prescribed pain medication to be administered every four hours. Resident #1 was not administered his/her medication from 10:00 pm on June 7, 2012, through 10:00 am on June 8, 2012, due to the facility not receiving the refill. The facility failed to administer Resident #1_x001A_s medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MF132735,70M002,ALF,3/21/2013,Resident #1 requested that Reported Perpetrator 2 (RP2) provide an evening treatment that is required for his/her medical condition. RP2 refused to provide the treatment to Resident #1. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MF133044,70M002,ALF,4/24/2013,The wheel fell off Resident #1's wheel chair and he/she fell out and hit his/her head and shoulder. The facility failed to provide a safe environment by not repairing the wheel chair when it was reported to have a problem. The failure is a violation of Oregon Administrative Rules.,2,,,, +MF134785,70M002,ALF,10/20/2013,Resident #1 was prescribed a prn anti-nausea medication. He/she requested the medication to be administered. It was not administered for three hours and 15 minutes after Resident #1 requested the medication. The facility failed to administer Resident #1's medication when requested. The failure is a violation of Oregon Administrative Rules.,2,,,, +MF134455,70M002,ALF,9/17/2013,A new order for barrier cream was received for Resident #1 on 8/23/13. On 9/18/13 the order for barrier cream had not been filled. The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving a prescribed medication. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS145659,70M002,ALF,1/10/2014,Resident #1 reported missing $40.00 from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MS147342,70M002,ALF,6/10/2014,Resident #1 reported $40.00 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MF149199,70M002,ALF,11/12/2014,It was reported that a medication card and count sheet for Resident #1's Diazepam were missing. Resident #1 received all his/her medications. An unknown individual was found responsible for the theft of Resident #1's medications which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MF150347,70M002,ALF,2/22/2015,"RV1 was a resident of the facility and was known to have a history of alcohol abuse and abusive behavior when intoxicated. On February 22, 2015 at approximately 5:00 pm RV1 was intoxicated and engaged in a loud verbal outburst in the dining area. RV2 attempted to calm RV1 but RV1 responded by making several rude and innapropriate statements. Law enforcement was contacted and escorted RV1 back to his/her room. Approximately ten minutes later, RV1 emerged and engaged RV3 in a verbal altercation. RV1 called RV3 an offensive name and threatened to punch RV3 in the face. RV3 stated that he/she was afraid at the time and did not know what to expect from RV1. There were no interventions in place concerning RV1's use of alcohol and no facility policy addressing the use of alcohol by residents. The facility failed to address RV1's negative behaviors and failed to appropriately care plan around those behaviors. The facility's failures are a violation of resident rights, are considered neglect and constitute abuse.",2,,,,Neglect +MS151729,70M002,ALF,6/25/2015,"The facility failed to provide a safe medication administration system regarding Resident #1_x001A_s medications. Resident #1 was transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +EN121550,70M003,ALF,6/9/2012,"Resident #1 was found on the floor of the bathroom in pain and bleeding from a head laceration. Resident #1 was a fall risk and had sustained previous falls. He/she was not wearing an alarm. It was stated that Resident #1 had been more confused with periods of worsening confusion recently. Resident #1 was not assessed for a change of condition. Resident #1 also endured additional pain and suffering due to being transported to the hospital in a vehicle instead of an ambulance being call. There was conflicting information regarding whether an ambulance was offered. The facility failed to implement additional fall interventions and assess Resident #1 for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +EN132455,70M003,ALF,2/15/2012,"Resident #1 fell on 2/15/12 and within hours was complaining of back pain followed by two days of decline. On 2/18/12 Resident #1 was taken to the hospital and it was determined he/she had sustained compression fractures in his/her back. There were also problems with the facility call system so Resident #1 was not able to call for help from staff when needed. The facility failed to implement additional fall interventions and assess Resident #1 for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +EN145649,70M003,ALF,1/26/2013,Resident #1 has a history of falls. He/she had a fall sustaining injury. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO14247,70M003,ALF,10/16/2014,"Resident #1 experienced significant weight loss and continued to lose weight. Resident #1 had a wound on his/her foot that became infected. The facility failed to ensure a registered nurse assessed and documented findings regarding residents who experienced a significant change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RD129076A,70M004,ALF,1/14/2012,"Resident #1 began to decline in early January and is now unable to assist with transfers. There have been instances when Resident #1 did not have assistance to the restroom and had to go in his/her briefs and then be cleaned up. There were no adjustments made to Resident #1_x001A_s care plan to reflect decline. The facility failed to provide sufficient staffing. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RD129076B,70M004,ALF,1/14/2012,Resident #1 requested additional pain medication. Resident #1 was given a prn over the counter pain medication without an order. Resident #1 did not suffer any side effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RD120432C,70M004,ALF,5/6/2012,A complaint was received that Reported Perpetrator (RP2) spoke to Resident #3 in an abrupt and unkind manner. The facility failed to assure that Resident #3 was treated with dignity and respect. The failure is a violation of Oregon Administrate Rules.,2,0,,, +RD146784,70M004,ALF,4/1/2014,"It was reported that Resident #1 was missing a metal tin from his/her room containing $9,448.00. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BR104224A,70M005,ALF,12/21/2010,Resident #1 did not receive his/her prescribed medication between approximately 11/19/10-1/14/11 and experienced increased frequency in behavior issues.,2,0,,, +BR132092,70M005,ALF,9/28/2012,Resident #1 was administered an incorrect medication by Reported Perpetrator 2. All parties were notified and he/she was placed on alert charting. The facility failed to provide a safe medication administration system.,2,,,, +BR133971,70M005,ALF,1/8/2013,"On 1/8/13, Resident #1 was administered incorrect medication. He/she was monitored and claimed to have slept well that night. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,,,, +BR132529,70M005,ALF,12/16/2012,In December 2012 the facility allegedly failed to provide a safe environment in relation to how residents were treated when they chose not to participate in care services. Reported Perpetrator #2 would loudly argue with residents when they refused care service. The facilities failure to ensure residents choice in treatment is a violation of residents rights and Oregon Administrative Rules.,2,,,, +BR132565,70M005,ALF,2/13/2013,"The facility administered ""house stock"" over the counter medication to Resident #1. The facility failed to ensure Resident #1 had a current physician order. The failure is a violation of resident rights and Oregon Administrative Rules.",2,,,, +BR135014,70M005,ALF,6/20/2013,"The facility failed to provide a safe medication administration system. Resident #1 received Resident #2's medication exposing them to potential harm. This violation is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BR148692,70M005,ALF,1/12/2014,The facility failed to administer Resident #1's medication as ordered. Resident #1 did not receive a dose of two different types of medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +BR146025,70M005,ALF,2/5/2014,The facility failed to administer Resident #1's medications as ordered. Resident #1 missed prescribed doses of different kinds of medication on 4 separate days. This failure is a violation of Oregon Administration rules.,2,,,, +BR146712,70M005,ALF,4/8/2014,The facility failed to adequately monitor Resident #1 for Elopement behavior. Resident #1 was able to leave the facility and was found walking along the road. This failure is a violation of Oregon Administrative Rules.,2,,,, +BR147787,70M005,ALF,6/18/2014,"The facility failed to adequately implement interventions relating to Resident #1s frequent falls. Resident #1 suffered several falls including a non-injury fall that took place in late May. The facility did not implement any additional interventions after the non-injury fall, and Resident #1 fell again sustaining a fractured hip. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BR149747,70M005,ALF,12/22/2014,"The facility failed to adequately monitor Resident #1. Resident #2 and Resident #1 hit each other after Resident #1 wandered into Resident #2's room. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BR151252,70M005,ALF,3/7/2015,The facility failed to provide medication as ordered. Resident #1 requested his/her as needed inhaler and it was not provided. Resident #1 missed one dose as a result. This failure is a violation of Oregon Administrative Rules.,2,,,, +BR148715,70M005,ALF,7/15/2014,"The facility failed to adequately monitor Resident #2 for redirection when wandering into other resident's rooms. Resident #2 entered Resident #1's room and pinched Resident #1 when asked to leave. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BR151139,70M005,ALF,1/15/2015,"Reported Perpetrator#2 (RP2) grabbed Resident #1's neck when trying to stop Resident #1 from falling. Resident #1 sustained a bruise as a result. RP2 is responsible for neglect of care, which constitutes abuse. The facility failed to provide Resident #1 with a safe homelike environment which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +BR151140,70M005,ALF,1/20/2015,The facility failed to provide a safe homelike environment in relation to inappropriate comments made to Resident #1 by Reported Perpetrator #2. This failure is a violation of Oregon Administrative Rules.,2,,,, +BR149744,70M005,ALF,12/14/2014,The facility failed to adequately ensure Resident #1 was treated with dignity and respect. Reported Perpetrator #2 made inappropriate verbal comments towards Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,,, +AS116643,70M007,ALF,2/21/2011,Resident #1 was administered his/her morning medications and felt he/she was treated roughly by Reported Perpetrator 2 (RP2). RP2 stated that he/she touched Resident #1 gently on the arm to awaken him/her to administer the medications and denied any rough handling occurred. Resident #1 had no physical injury identified; however he/she verbalized pain in both upper arms.,2,0,,N/A, +AS120730,70M007,ALF,8/1/2012,Resident #1 was discovered in his/her wheelchair soiled with his/her garments around his/her knees. He/she had been transferred by the caregiver who had not come back for an extended amount of time. Resident #1 transferred self his/her back to wheelchair. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrate Rules.,2,0,,, +AS121291,70M007,ALF,10/9/2012,Resident #1 expressed that Reported Perpetrator 2 (RP2) was rough and rushed when transferring him/her. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +AS150961,70M007,ALF,4/14/2015,"The facility failed to adequately assess and intervene when Resident #1 attempted to attack a care giver with a knife. After care staff had taken the knife away and escorted him/her to their room Resident #1 pushed Resident #2 down and pulled his/her hair. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +AS151709,70M007,ALF,6/19/2015,"Residents #1, #2, and #3 had medication go missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD105971B,70M008,ALF,10/2/2010,"A resident of the Facility received his/her prescribed routine pain medication, which was administered by Facility staff, outside of the parameters indicated by the physician. The resident was not noted to have suffered any negative outcome as a result of this medication error; however the resident received the incorrect dosage from time of admittance until it was discovered, so the resident's baseline was not established.",2,0,,, +RD105971C,70M008,ALF,10/2/2010,"A resident of the Facility, who was known to have bowel obstructions, was having his/her bowel movements monitored and recorded by staff. The resident began complaining of pain and went to a scheduled physician's visit, where it was discovered he/she was severely constipated. It was determined the last documented bowel movement had occurred 11 days prior. Facility staff did not document the resident's increase in pain, or notify the physician of the resident_x001A_s lack of bowel movements. The resident's severe constipation caused the resident unnecessary discomfort.",2,0,,,Neglect +CO12130,70M008,ALF,11/17/2012,"The facility failed to evaluate and monitor changes of condition and refer a significant change of condition to the RN for Resident #1, related to behaviors and weight loss. Resident #1 had significant weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD133328,70M008,ALF,5/8/2013,"It was reported that the facility failed to protect Resident #1 from misappropriation of narcotic medication. Upon investigation, the investigator was unable to determine if Resident #1_x001A_s narcotic medication had been misappropriated.",,,,, +BO146766,70M008,ALF,4/11/2014,Reported Perpetrator 2 (RP2) was given a check for $400 from Resident #2. The investigator was unable to find any evidence of missing medications. It was determined that RP2 was determined to be responsible for financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Financial abuse +BO148831,70M008,ALF,8/25/2014,"Resident #1 gave Reported Perpetrator #2 (RP2) $200, and RP2 accepted the money. RP2 is responsible for financial exploitation which constitutes abuse. The facility failed to protect Resident #1 from financial exploitation. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BO149071,70M008,ALF,8/19/2014,"Resident #1 had pain medication go missing after it was delivered to the facility. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BO159925,70M008,ALF,11/1/2014,"Resident #1 had pain medication go missing. Reported Perpetrator #2 was found responsible for taking the medication which is theft of property, and constitutes abuse. The facility failed to protect Resident #1's property from theft. This is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD150574,70M008,ALF,2/8/2015,The facility allegedly failed to properly care for Resident #1's colostomy bags. An investigation determined the allegation did not occur.,,,,, +OR0001000002,70M008,ALF,9/4/2015,,0,,,Substantiated, +RB132431,70M009,ALF,2/7/2013,"Resident #1 was a fall risk. His/her care plan stated that staff would provide Resident #1 with hands on assistance for all transfers. Resident #1 fell in his/her room while attempting to sit in his/her wheelchair, the brakes were not locked. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RB146982,70M009,ALF,5/1/2014,"The facility ran out of Resident #2's narcotic pain medication resulting in unreasonable discomfort. The facility failed to ensure a safe medication administration system resulting in unreasonable discomfort. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RB148961,70M009,ALF,10/14/2014,RP2 yelled and threatened Resident #1 resulting in emotional harm. Facility conducted an internal investigation and RP2 was ultimately terminated. The facility failed to ensure Resident #1 was treated with dignity and respect and is a violation of Oregon Administrative Rules. RP2 was found responsible for verbal abuse.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RS150760,70M009,ALF,3/22/2015,Resident #1 had a condition that requires complete supervision and a history of unsafely wandering and exit seeking after her/his spouse visits. The facility failed to adequately monitor as care planned resulting in Resident #1 leaving the facility unattended. Resident #1 was returned to the facility unharmed. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD116812,70M010,ALF,3/14/2011,Resident #1's colostomy bag care was not addressed for approximately seven hours from the time he/she requested assistance. The facility failed to provide care timely to his/her needs and risk of skin breakdown.,2,0,,, +RD120274,70M010,ALF,5/6/2012,Resident #1's medication patch was not removed as described in his/her medication administration record. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RD148557,70M010,ALF,7/31/2014,"Resident #1's medication went missing from the facility medication cart. This medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD116849A,70M013,ALF,3/29/2011,"A resident of the Facility who was a two-person assist for transfers was left to become incontinent in his/her bed at night due to the Facility only staffing one caregiver. Facility staff planned to provide incontinent care following an episode of incontinence, rather than transfer the resident to the toilet. Additionally, on two separate occasions the local fire authority had to be dispatched to assist the resident off the floor due to not having enough staff to assist the resident.",2,0,,, +RD151569A,70M013,ALF,12/21/2014,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD151569B,70M013,ALF,12/21/2014,"Resident #1 had gift cards go missing from his/her room. The cards were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +CO11057,70M014,ALF,3/9/2011,"The facility failed to evaluate and monitor a resident who had a change in condition; failed to document the changes, refer significant changes to the facility RN, follow physician orders and update the service plan for Resident 2. Resident 2 experienced low blood sugars that required treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES117095,70M014,ALF,5/27/2011,The facility failed to provide a safe environment resulting in the loss of money from Resident #1's room. Abuse was apportioned to an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +ES133210,70M014,ALF,5/2/2013,"Resident #1 reported an electronic item was taken from his/her apartment. Witnesses stated they saw the item in Resident #1's room and did not see him/her with it outside of their room. The item was not found. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person removed the item from Resident #1's room, which is considered financial exploitation and constitutes abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +ES135042,70M014,ALF,11/6/2013,"Reported Perpetrator #2 failed to change Resident #1's wound dressing as was ordered, and Resident #1's wound worsened as a result. This failure is considered neglect of care and constitutes abuse. The facility failed to ensure Resident #1 received care as ordered. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +ES145933,70M014,ALF,1/23/2014,"Resident #1 had $49 cash missing from her/his room while at the hospital. Investigation was initiated and theft reported to local law enforcement. No suspects were identified. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB129963,70M015,ALF,5/3/2012,"Resident #1 was in the facility for a short stay. Upon going home, a family member noticed Resident #1_x001A_s earrings and two rings were missing. An unknown individual was determined to be responsible for the theft. The facility failed to provide a safe environment for Resident #1 resulting in the loss of property. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +HB132883,70M015,ALF,4/9/2013,"Resident #1's Care Plan stated one selected staff member would assist Resident #1 with cleaning while he/she was present in the apartment. Staff members purposely cleaned Resident #1's apartment while he/she was not at the facility and independently made the decision to remove Resident #1's personal items in various manners, such as storing them or giving them away. The facility's action is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,,,,Financial abuse +HB149145,70M015,ALF,11/4/2014,The facility failed to administer Resident #1's gastrointestinal medication as ordered. Resident #1 missed doses of medication as result. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB149373,70M015,ALF,9/23/2014,"The facility failed to implement adequate interventions related to Resident #1s fall risk. Resident #1 sustained a fall with bruising to his/her shoulder. The facility did not implement any further interventions. Resident #1 fell again the next day and required sutures for a laceration he/she received during the fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB149338,70M015,ALF,11/24/2014,"Resident #1 had medication go missing from the facility. The medications were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB149467,70M015,ALF,12/4/2014,"Resident #1 had money taken from his/her room. The money was taken by an unknown individual, and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB152229,70M015,ALF,7/27/2015,"Resident #1 had medication go missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB153645X,70M015,ALF,11/19/2015,"Residents #1 and #2 had money go missing from their rooms. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +AL116309,70M016,ALF,10/30/2010,A resident of the Facility received incorrect medication from Facility staff. By receiving the wrong medication the resident was placed at moderate risk of harm. The Facility detected the error right away and began monitoring the resident's condition. The resident did not experience any actual harm as a result of the medication error.,2,0,,, +AL117455B,70M016,ALF,9/15/2010,"A resident of the Facility failed to receive ordered medication for a prolonged period of time. During the investigation two different copies of the resident's MAR (medication administration record) were obtained, which demonstrated a falsification of records with respect to the medication that was not administered.",1,0,,, +AL117455C,70M016,ALF,9/15/2010,A resident's physician ordered the start of a specific medication to which Facility staff failed to administer for a prolonged period of time.,1,0,,, +AL128825A,70M016,ALF,7/20/2011,Resident #1 did not receive his/her medications as prescribed.,2,0,,, +AL128825B,70M016,ALF,7/20/2011,"Resident #1 moved out of the facility on July 20, 2011. Another resident's prescription narcotic medication was sent with Resident #1.",2,0,,, +AL128969,70M016,ALF,7/29/2011,"Resident #2 was found on the floor and transported to the hospital. Resident #2 sustained a fractured hip, wrist and rib. Resident #1 said his/her motorized wheelchair hit Resident #2. Resident #1 has a history of impatient behaviors when using his/her motorized chair. The facility failed to appropriately address Resident #1_x001A_s aggressive behaviors with motorized wheelchair resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AL121327,70M016,ALF,8/12/2012,"Resident #1 was found in the late afternoon in the courtyard unresponsive with apparent heat exhaustion. He/she had gone out to sit in the sun after lunch. His/her wheelchair had gotten stuck and he/she was unable to maneuver back inside. 911 was called and Resident #1 was transported to the hospital. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AL145972,70M016,ALF,6/7/2013,"Resident #1 was observed to have cognitive decline by Witness #1. The facility had noticed a change in RV1's behavior a few weeks prior but didn't deem it necessary to contact family or report to his/her physician. Due to witness #1's concern, Resident #1's physician was contacted and he/she was treated with antibiotics and showed significant improvement. The facility failed to intervene when Resident #1's condition changed. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL147092,70M016,ALF,11/18/2013,"It was discovered that the narcotic count was off by five pills when the count was completed. Reported Perpetrator 2 (RP2) admitted that he/she counted medications and signed the narcotic log book as accurate, he/she did not count the medications that were in prescription bottles. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL150852C,70M016,ALF,7/24/2014,"Resident #1 frequently refuses showers. His/her service plan states to + +re-approach and offer a shower time that is reasonable. The facility failed to follow Resident #1_x001A_s service plan regarding shower refusal. The failure is a violation of Oregon Administrative Rules.",2,,,, +AL152066,70M016,ALF,10/28/2014,The facility failed to adequately care plan for Resident #1's fall risk. Resident #1 suffered one non-injury fall and the facility failed to implement any additional fall preventions. Resident #1 fell again with no injuries. This failure is a violation of Oregon Administrative Rules.,2,,,, +AL152478,70M016,ALF,10/5/2014,The facility failed to adequately provide a safe medication administration system. Resident #1 was not given doses of two different medications. This failure is a violation of Oregon Administrative Rules.,2,,,, +MM117476,70M017,ALF,6/30/2011,RP2 was verbally inappropriate in the presence of Resident #1. The facility failed to assure resident rights resulting in a loss of dignity.,2,0,,, +MM117589,70M017,ALF,6/30/2011,The facility failed to provide a safe medication administration system resulting in the loss of resident narcotic medications. RP2 and the facility were both apportioned abuse.,2,0,Substantiated,Substantiated,Financial abuse +MM118269B,70M017,ALF,10/7/2011,"Resident #2's test results were ""high"" and he/she was administered medication without notifying his/her physician as ordered. Resident #2 was exposed to potential harm.",2,0,,, +MM120231,70M017,ALF,6/5/2012,"Resident #1 was a two person transfer with the use of a gait belt for all transfers. He/she was transferred by one staff person without a gait belt and sustained a laceration to his/her right ankle during the transfer. Resident #1 was transported to the hospital and required stitches. The facility failed to follow Resident #1_x001A_s service plan and failed to ensure staff were oriented to his/her service plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM132477,70M017,ALF,2/13/2013,Resident #1 went into Resident #2_x001A_s room. He/she slapped Resident #2 and Resident #1 sustained a skin tear on his/her hand. Resident #1 had other incidents of wandering into other residents rooms. No changes to his/her service plan or interventions were implemented. The facility failed to update Resident #1_x001A_s service plan to address his/her behaviors. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM134142,70M017,ALF,8/12/2013,Resident #1 and was given extra doses of an ordered medication. Resident #2 did not receive an ordered medication. The computerized Medication Administration Record (MAR) contained errors. Training materials did not alert staff to the possibility of duplicate orders or tell staff to check to see if they had been duplicated. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM121583,70M017,ALF,10/3/2012,"Resident #1 was administered another resident's medication. The error was discovered immediately and Resident #1 was transported to the hospital, treated and released back to the facility the same day. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +MM148428,70M017,ALF,9/2/2014,"Resident #1 had a physician's order to rinse his/her dentures in a solution of ten percent bleach. Resident #1 developed swelling and burns to his/her lips and tongue. The facility failed to assess, care plan and appropriately monitor Resident #1 after a change of condition. + +The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM147458,70M017,ALF,6/6/2014,Resident #1 had an order from his/her physician to discontinue a pain medication on 5/27/14. The pain medication continued to be administered until 6/6/14. Resident #1 had no negative outcome. Medications were also left on the med carts for extended periods of time after orders to discontinue had been received. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM147932,70M017,ALF,7/28/2014,"Resident #1 had personal property go missing from his/her room. These items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MM150814,70M017,ALF,3/31/2015,"The facility failed to assess and intervene when Resident #1 was observed to inappropriately touch another resident. Resident #1 inappropriately touched another resident. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +CO12089,70M018,ALF,3/30/2012,"The facility failed to ensure residents were evaluated and monitored according to their needs and a referral was made to the facility RN. The facility also failed to ensure residents who experienced a change of condition were assessed by an RN. Resident #2 had a pressure ulcer that worsened. Resident #6 experienced a severe weight gain in one month. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,,Neglect +DA132397,70M018,ALF,2/9/2013,Resident #1 reported $65.00 missing from his/her room. An unknown individual was found responsible for the loss of Resident #1_x001A_s money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +DA148837,70M018,ALF,9/29/2014,The facility failed to provide a safe medication administration system by not checking Resident #1's medications for accuracy when Resident #1 requested. It is the facility policy to recheck the medication up request from a resident. This failure is a violation of Oregon Administrative Rules.,2,,,, +DA149728,70M018,ALF,12/23/2014,"Money went missing from Resident #1's room. An unknown individual took the money and this person is responsible for theft theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +WB117300B,70M019,ALF,6/12/2011,Undue influence was used when Resident #1 signed a contract by the Facility who was aware that he/she had notable cognitive issues.,2,0,,,Financial abuse +WB117402,70M019,ALF,7/6/2011,The facility failed to provide catheter care to Resident #1 timely.,2,0,,, +WB134096,70M019,ALF,8/7/2013,Resident #2 had a history of aggression with staff and one altercation with another resident before slapping Resident #1's elbow. Resident #1 did not sustain any injuries. The incident took place in the dining room where staff was not always able to view all residents at the same time. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH105723,70M020,ALF,11/2/2010,"Complainant reported that someone broke into Resident #1's lockbox and took money out of it. RP2 was suspected of the theft, however there was no evidence to determine culpability. The facility failed to provide a safe environment resulting in the loss of resident's money. The abuse was apportioned to an unknown person.",2,0,Not Substantiated,Substantiated,Financial abuse +BH118557,70M020,ALF,11/26/2011,Resident #1 and Resident #2 reported missing money and jewelry from the locked drawer in their room. The locked drawer was bent and the residents always lock their door. The facility failed to provide a safe environment resulting in the loss of resident properly. An unknown individual was found responsible for abuse.,3,0,Not Substantiated,Substantiated,Financial abuse +BH120960,70M020,ALF,8/24/2012,It was reported that Reported Perpetrator 2 (RP2) fraudulently signed the Registered Nurse's name to the narcotics book and stated he/she (RP2) destroyed narcotic medications on his/her own. Reported Perpetrator 3 (RP3) stated he/she did not monitor the narcotic sheets for accuracy. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated, +BH134637,70M020,ALF,10/3/2013,"Security cameras revealed Reported Perpetrator 2 (RP2) taking medication out of the medication cart. RP2 did not document giving medications to anyone and was not seen going into Resident #1's room. Resident #1 had two dosages of medication missing the following day. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for taking Resident #'1 medication, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BH146256,70M020,ALF,1/29/2014,"Three residents reported missing items from their respective rooms including cash and jewelry. RP2 and RP3 were suspected, however it was unable to be verified who took the items. Both RP2 and RP3 no longer work at the facility. The facility failed to ensure a safe environment resulting in the loss of residents' property. The failure is a violation of Oregon Administrative Rules. An unknow person was found responsible for the thefts, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +BH151555,70M020,ALF,6/4/2015,"Complainant reported that the facility was not ensuring adequate staff to meet resident care needs. Investigative findings revealed that only one caregiver on schedule with multiple two person transfers including Resident #1. Resident #1 was left incontinent for several hours until a second staff person came in to assist with the transfer. The facility failed to provide appropriate staffing to meet resident care needs resulting in incontinence and potential for serious harm. The failures are violations of resident rights, is considered neglect of care and constitute abuse.",3,500,,,Neglect +BH151190,70M020,ALF,4/21/2015,"Resident #1 returned from the hospital and was put on alert charting, however the facility failed to document or notify oncoming staff of the resident's return. Resident #1 was not checked on until the following morning where she/he was found on the floor for an undisclosed time and required transportation to the hospital. The facility failed to adequately monitor Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however not issued due to a change of owner on May 1, 2015.",3,,,,Neglect +OT116210B,70M021,ALF,1/1/2011,"The facility failed to provide adequate oversight and monitoring resulting in Resident #1 being transported to the hospital. The facility also failed to adequately care plan after Resident #1 experienced a significant change of condition resulting in being transported to the hospital again for injury fall. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +OT116365A,70M021,ALF,12/3/2010,"The facility failed to appropriately plan care and monitor Resident #1's skin due to her/his diagnosis and condition resulting in skin wounds to develop. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +CO11125,70M021,ALF,9/22/2011,"The facility failed to ensure service plans were reflective of Resident #2_x001A_s current needs and failed to evaluate, monitor, develop interventions and/or refer for assessment. The facility also failed to provide an RN assessment for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes of condition. Resident #3 had a severe weight loss. Resident #2 had significant weight loss and repeated skin breakdown. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +OT118563,70M021,ALF,10/13/2011,"The facility failed to answer call lights in a timely manner resulting in incontinence and unreasonable pain from not receiving pain medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +OT118559,70M021,ALF,10/9/2011,"Staff discovered 10 of Resident #1's narcotic pills replaced with another brand. Facility staff were aware of the sale, distribution and consumption of narcotic medications by other facility staff but failed to report it. It is unknown if other residents' narcotics were affected. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. Both the facility and RP2 are found responsible for abuse.",2,0,Substantiated,Substantiated,Financial abuse +OT129556,70M021,ALF,3/9/2012,Resident #1 had a history of calling to request pain medication. RP2 administered a sleep aide to Resident #1. Resident #1 did not have an ordered for a sleep aide. The facility failed to ensure a safe medication administration system resulting in the potential for harm to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO14054,70M021,ALF,11/21/2013,"The facility failed to coordinate care with on/off site providers for Residents #1, #2 and #4, who received home health services. Resident #4 was transported to the hospital after a urinary catheter was placed. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +OT134465B,70M021,ALF,6/18/2013,"Resident #1 was admitted back to the facility after a Nursing Facility stay. According to the facility Resident #1 did not have doctor_x001A_s orders for medications upon return. Resident #1 went without his/her medications from June 18, 2013 to June 22, 2013. The facility failed to obtain doctor_x001A_s orders for Resident #1_x001A_s medications. The failure is a violation of Oregon Administrative Rules.",2,,,, +OT134884,70M021,ALF,9/3/2013,Resident #1 missed the 8:00 a.m. and 12:00 p.m. dose of his/her seizure medication due to the medication being unavailable. The facility failed to administer Resident #1_x001A_s medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +OT145566A,70M021,ALF,6/25/2012,"Resident #1's medication was being administered outside parameters. + +The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +OT145620,70M021,ALF,9/5/2012,Resident #1 was given another resident_x001A_s medication. The facility failed to provide a safe medication administration system resulting in Resident #1 being hospitalized. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO11076,70M022,ALF,5/3/2011,"The Facility failed to evaluate changes in condition, develop interventions, monitor the changes, make referrals to the RN, and conduct an RN assessment of changes that occurred. These failures resulted in residents_x001A_ medical conditions worsening. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RB118480,70M022,ALF,11/12/2011,"Resident #1 discovered money missing from the locked drawer in her/his room on or about November 15, 2011. Internal investigation was conducted and law enforcement was contacted. An unknown person was found responsible for abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +RB121386,70M022,ALF,10/19/2012,Resident #1's care plan instructed staff to reminder him/her to brush teeth and assist as needed. His/her dentures were discovered covered in black mold and had been that way for some time. The facility failed to provide or assist with Resident #1's hygiene. The failure is a violation of Oregon Administrative Rules.,2,0,,,Neglect +RB132903,70M022,ALF,4/8/2013,"Documentation stated Resident #1 was an extreme fall risk and there was a physician's order in place stating the need for no un-assisted ambulation. Resident #1 had two un-witnessed falls; the latter resulting in a fractured bone and surgery. The facility failed to follow Resident #1's Service Plan. The failure is a violation of Resident's Rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB133141,70M022,ALF,5/4/2013,"Reported Perpetrator 2 (RP2) left Witness 3's medications on the table. Resident #1 took Witness 3's medication. Resident #1 was transported to the hospital where it was discovered his/her blood sugar level dropped significantly. Witness #1 confirmed RP2 was directed to leave the medications on the table and it was the practice for all staff on Saturday mornings. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB149359,70M022,ALF,11/1/2014,"The facility failed to adequately monitor Resident #2. During and altercation with Resident #3, Resident #2 put a plastic bag over Resident #3's head. No injuries occurred from the altercation. This failure is a violation of Oregon Administrative Rules.",2,,,, +RB159836,70M022,ALF,1/6/2014,The facility failed to adequately monitor Resident #1's behavior in relation to wandering into other resident's room. Resident #1 wandered into Resident #2's room and a resident to resident altercation ensued. This failure is a violation of Oregon Administrative Rules.,2,,,, +RS154063,70M022,ALF,10/26/2015,The facility failed to provide a safe medication administration system. Resident #1 missed one dose of his/her medication as facility staff could not find it. This failure was a violation of Oregon Administrative Rules.,2,,,, +BC116980,70M023,ALF,5/5/2011,The facility failed to have a safe medication administration system for tracking liquid controlled substances. The counts for liquid medication for Resident #1 and Resident #2 did not match the documented administration of said medication.,2,0,,, +BC116831,70M023,ALF,3/29/2011,Medications were discovered missing from Resident #1's apartment. He/she had a locking box in his/her room; however placed the medications into an unlocked dresser drawer. All staff worked during the time period and had keys to access his/her apartment. The abuse is apportioned to an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +BC132396,70M023,ALF,1/28/2013,"Resident #1's, Resident #2's, and Resident #3's blood pressure did not get checked before administering their medications. The facility failed to follow physician's orders. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC132364,70M023,ALF,1/28/2013,The facility failed to provide a safe environment resulting in the loss of Resident #1's money from his/her room. An unknown individual is responsible for the theft of money. The facility's failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC135312,70M023,ALF,11/26/2013,"Resident #1 suffered an un-witnessed fall and Reported Perpetrator 2 (RP2) responded to his/her call light. RP2 assisted Resident #1 with transfers twice, waiting approximately 50 minutes before reporting the fall and Resident #1's pain to a nurse for assessment. Resident #1 was found to have fractured his/her hip in the fall. RP2 was found responsible for neglect of care and constitutes abuse. The facility failed to ensure Resident #1's injuries were assessed timely which is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +KF103670,70M024,ALF,3/3/2010,"Resident #1 felt he/she was treated poorly due to his/her client status. His/her care needs increased drastically due to a medical event, and some felt it was questionable that he/she actually needed the increased care. Documented medical evidence listed unpredictable care needs that required staff to stand by assist.",2,0,,, +KF121822A,70M024,ALF,11/28/2012,"Resident #1 had a diagnosis related to memory loss and was care planned to require total assist with most ADLs (Activities of Daily Living) including toileting, feeding, and repositioning. Witness testimony revealed the facility failed to provide care needs as directed resulting in poor continuity of care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF118768,70M024,ALF,12/22/2011,Although Resident #'1s Medical Administration Record stated he/she received his/her daily pain medication; a blood test revealed Resident #1 had not taken the prescribed medication. The facility failed to administer ordered medication. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF133563,70M024,ALF,6/10/2013,"Resident #1 had a cell phone that she/he ""lived"" off of taken from her/his room. Witness #1 searched for the cell phone and reported the incident immediately to appropriate staff. Facility failed to immediately report the incident to appropriate authorities or timely complete an internal investigation. The failures are violations of Oregon Administrative Rules. An unknown was held responsible for the loss of resident property, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +KF135102,70M024,ALF,11/16/2013,"Resident #1 reported $20 plus coins missing after returning from the hospital. Witness #1 put the satchel in Resident #1's room and locked it. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rule. An unknown person was held responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +KF146745,70M024,ALF,4/8/2014,"The facility failed to adequately plan, assess and implement interventions to prevent Resident #1's falls. Resident #1 fell three times at the facility requiring ER care after the second fall. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF147759,70M024,ALF,7/15/2014,"Residents #1 and #2 had money go missing from their rooms. These items were taken by an unknown individual, and this person is responsible for theft of property which is considered financial exploitation and constitutes abuse. The facility failed to protect both resident's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +KF148342,70M024,ALF,8/29/2014,"Resident #1 suffered a change of condition and exhibited cognitive impairment resulting from increased use of pain medication. The facility failed to provide adequate interventions to prevent falls when Resident #1 exhibited cognitive impairment symptoms. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",3,300,,,Neglect +KF148142,70M024,ALF,8/13/2014,"The facility failed to assess and intervene when Resident #1 suffered a change of condition. Resident #1 developed anxiety and would attempt to ambulate to his/her doorway to yell for help rather than using his/her call light. He/she suffered falls, including one with an injury to his/her head, while attempting to ambulate without assistance. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +KF148846,70M024,ALF,10/4/2014,"The facility failed to adequately monitor Resident #1 when his/her conditioned changed. Resident #1 fell in his/her bathroom and struck their head. Resident #1 was left alone in his/her room after the fall and fell again sustaining a hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF150830,70M024,ALF,3/17/2015,"The facility failed to adequately assess and intervene when Resident #1 sustained several falls. Resident #1 fell again and sustained an injury requiring surgery. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +SV116994,70M025,ALF,5/9/2011,"A resident of the Facility who required assistance from staff for transferring to and from the commode was left without assistance, and no way to call for assistance, for approximately one hour. The resident was found by his/her family who obtained assistance from Facility staff.",2,0,,,Neglect +SV129688,70M025,ALF,3/16/2012,"Resident #1, #2 and #3 reported rings missing from their respective rooms. Resident #1 also had money missing. An unknown individual was determined to be responsible for the theft. The facility failed to provide a safe environment for residents resulting in loss of property. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +MV120658,70M025,ALF,7/24/2012,Resident #1 inappropriately touches staff and other residents. The facility failed to address Resident #1_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +WB121946,70M025,ALF,12/19/2012,Resident #1 reported money missing from his/her dresser drawer where he/she had hidden it. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MV132462,70M025,ALF,1/27/2013,"Resident #1 was a fall risk and had several falls, two of which caused injury. There were no amendments to his/her service plan after each fall. On January 27, 2013, Resident #1 had three falls and was taken to the hospital twice. The facility failed to update Resident #1's service plan to address fall interventions and assess Resident #1 for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +WB133485,70M025,ALF,6/5/2013,"A witness said Reported Perpetrator 2 (RP2) stated Resident #1 purchased a computer for RP2 and said Resident #1 was easy to get money from. Resident #1's family stated he/she had some checks written recently that he/she was unable to account for. It was also reported RP2 used Resident #1's vehicle, which RP2 admitted to doing on at least one occasion. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for taking items of value from Resident #1, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +MV134695A,70M025,ALF,9/19/2013,Resident #1 was care planned as a two person transfer with gait belt for all transfers due to a change of condition. Resident #1 was using the restroom and called out for assistance due to his/her legs buckling. Resident #1 sustained abrasions to his/her knees. Reported Perpetrator 2 (RP2) did not assist. The facility failed to follow Resident #1's care plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV134695B,70M025,ALF,9/19/2013,It was reported that Reported Perpetrator 2 (RP2) made inappropriate verbal comments to Resident #1. Resident #1 was upset and offended by RP2_x001A_s question/statement. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +MV132977,70M025,ALF,3/7/2013,The facility failed to follow Resident #1's care plan and provide hourly checks and repositions of Resident #1. Facility staff did not check Resident #1 between 3:30 and 5:25. This failure is a violation of Oregon Administrative Rules.,2,,,, +MV135143,70M025,ALF,11/20/2013,"A concern was raised that Reported Perpetrator 2 (RP2) had misappropriated resident monies. It was determined that $5,800 was missing and unaccounted for. RP2 was found responsible for theft of money from the facility and residents which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES118264,70M026,ALF,10/17/2011,"Resident #1 required assistance with transfers. On or about October 17, 2011 Resident #1 transferred self to the bathroom and back to living area after staff failed to answer call light. Resident #1 was found on the floor and was transported to the hospital for treatment of a fractured hip. It was later discovered that the call light system was unplugged. The facility failed to have a functioning call system resulting in a fall with injury. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,250,,,Neglect +ES129666,70M026,ALF,4/2/2012,"Reported Perpetrator 2 (RP2) picked Resident #1 up from his/her previous facility, using the facility van. RP2 incorrectly secured Resident #1's wheelchair into the van. Resident #1 fell over in the van while in transport, resulting in an injured neck which was diagnosed at a medical facility. Facility administration stated RP2 was not trained property in securing a wheelchair in the van. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,,,,Neglect +ES153250,70M026,ALF,10/12/2015,"The facility failed to provide qualified caregiver to adequately transfer Resident #1. Resident #1 sustained an ankle injury as a result of the transfer. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DL121008,70M028,ALF,9/5/2012,"Resident #1 was found in his/her room disoriented and confused, and was admitted to the hospital with a diagnosis_x001A_s of dehydration, renal failure and over medication. The facility failed to follow Resident #1_x001A_s care plan resulting in hospitalization. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DL132192,70M028,ALF,1/3/2013,Resident #1 received several wrong doses of medication. The medication error resulted in Resident #1 receiving Resident #2_x001A_s medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DL133436B,70M028,ALF,6/5/2013,Resident #1 is prescribed both a scheduled and PRN narcotic pain medication to treat chronic pain. The facility ran out of his/her PRN narcotic pain medication. Resident #1 went without his/her PRN narcotic pain medication for three days. Resident #1 experienced increased pain as a result. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +DL132563B,70M028,ALF,3/5/2013,Resident #1_x001A_s CBG_x001A_s were not being accurately recorded in his/her Medication Administration Record (MAR). The facility failed to keep Resident #1_x001A_s medication record accurate. The failure is a violation of Oregon Administrative Rules.,2,,,, +DL132563A,70M028,ALF,3/5/2013,"Resident #1 was prescribed a pain patch to be changed every 72 hours for chronic pain. Resident #1 was acting in an uncharacteristic manner toward family and friends. The Medication Administration Record (MAR) documentation indicated that the patch had been changed. It was discovered that the patch had not been changed for six days resulting in Resident #1 experiencing withdrawal symptoms. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DL133268,70M028,ALF,5/18/2013,"Resident #1 and Resident #3 were affected by Resident #2's sexual behaviors and were exposed to potential for serious harm. Resident #2 had a history of making inappropriate sexual comments to staff and residents. The facility failed to care plan appropriately and implement interventions regarding Resident #2's sexual behaviors. The facility also failed to notify Resident #2's physician of his/her behaviors. The failure is a violation of resident rights, is considered neglect of care resulting in sexual abuse.",3,2500,,,Sexual abuse +DL148109,70M028,ALF,8/9/2014,Resident #2 had behavior issues relating to inappropriate touching and comments to residents of the opposite sex. Resident #2 kissed Resident #1 without permission. The facility failed to assure Resident #1's resident rights and implement interventions to address Resident #2's behaviors.,2,,,, +DL148476,70M028,ALF,9/9/2014,Resident #1 was upset regarding how Reported Perpetrator 2 (RP2) treated him/her during care or requests for care. There were multiple complaints made to facility management regarding RP2. The facility failed to investigate the complaints and report to APS. The facility also failed to provide a safe environment and assure resident rights. The failures are a violation of Oregon Administrative Rules.,2,,,, +DL150178,70M028,ALF,2/5/2015,"Resident #1 was prescribed a narcotic pain patch to be changed every seventy-two hours. On February 1, 2015, a new patch was not available due to the facility being out. Resident #1 experienced pain due to not receiving the pain patch. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DL150611,70M028,ALF,3/11/2015,Reported Perpetrator 2 (RP2) asked Resident #1 to borrow $200.00. RP2 signed an IOU for $200.00. Resident #1 gave RP2 his/her debit card and PIN number. It was discovered that a total of $500.00 had been withdrawn from Resident #1's account. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +HB116839,70M029,ALF,4/27/2011,The facility failed to notify APS and Local Law Enforcement after it was reported that medications went missing from Resident #1's apartment. The failure is a violation of OARs.,2,0,,, +HB121334,70M029,ALF,10/16/2012,"Several incidents of missing of jewelry were reported by multiple residents. Police were notified and RP2 was suspected and found responsible for the thefts, is considered financial exploitation and constitutes abuse. The facility failed to provide a safe environment. The facility also failed to report the thefts or conduct an internal investigation. The failures are violaitons of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +DA116938,70M030,ALF,5/8/2011,"The facility failed to provide a safe environment by not adequately assessing or care planning care needs, nor providing clear direction to staff to properly provide care for Resident_x001A_s #1 - #4 who experienced increased needs and/or a change of condition. The Facility_x001A_s failures resulted in potential for serious harm, are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA117597,70M030,ALF,6/14/2011,The facility failed to provide a safe environment and implement effective interventions due to Resident #1's increased behaviors of threatening other residents and staff with a knife.,12,0,,, +DA117985,70M030,ALF,9/12/2011,"Resident #1 and Resident #2 have had verbal and physical conflicts that have gradually escalated from 4/2011 to 9/2011, resulting in harm to Resident #1. The facility failed to address residents' behaviors and implement new interventions.",2,0,,,Neglect +DA129869,70M030,ALF,3/25/2012,"Between 3/22/12 and 3/25/12, a ring on Resident #1's finger, worth an estimated $5,000 was pulled off his/her finger leaving marks on his/her finger. An unknown individual is responsible for the theft of Resident #1's ring. The facility failed to investigate, document, and report to the appropriate authorities. The failures are a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +DA120462,70M030,ALF,7/8/2012,"The facility failed to administer Resident #1's pain medication timely and failed to administer a scheduled pain patch. Resident #1 experienced continued pain. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +DA120439,70M030,ALF,6/18/2012,The facility failed to administer Resident #1 his/her physician ordered medication for approximately eight days. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA121455,70M030,ALF,10/26/2012,"Resident #1 was left on the toilet for approximately one hour with the call bell on. Witness 2 and Resident #1 waiting and when staff didn't respond, Witness 2 assisted Resident #1 to bed. The facility failed to provide timely service to Resident #1. The failure is a violation of Oregon Administrative Rules.",2,0,,, +CO13026,70M030,ALF,2/28/2013,"The Facility failed to ensure Resident #3 was evaluated and monitored according to his/her change of condition; and failed to ensure his/her service plan was reflective of his/her needs and were consistently followed. Resident #3 suffered injuries from falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA132815,70M030,ALF,4/2/2013,Resident #1's pain medications were administered as ordered and within the one hour window before or after the time noted to administer. Resident #1 was given a new medication on 3/18/13; however he/she did not start taking the medication until 3/28/13. The facility failed to administer Resident #1's ordered medications. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA132878,70M030,ALF,3/5/2013,"The facility administered medication to Resident #1 without physician's orders; and prepared his/her Medication Administration Record (MAR) without physician's orders, and failed to follow its own orders because the medication could not be found.",2,0,,, +DA133264,70M030,ALF,5/17/2013,The facility failed to timely answer Resident #1's call light when he/she needed assistance. The facility failed to conduct a facility investigation of the incident. The failures are a violation of Oregon Administrative Rules.,2,,,, +DA133556,70M030,ALF,6/12/2013,Witness reported facility staff routinely fail to respond to resident call lights in a timely manner. On two occasions Resident #1 requested assistance by pulling the call light cord and calling the front desk for assistance; on both dates response times were delayed by a factor of hours. The facility failed to answer a call light in a timely manner. The failure is a violation of Oregon Administrative Rules.,2,,,, +DA133304,70M030,ALF,3/27/2013,"The Facility failed to respond to Resident #1_x001A_s call light when he/she experienced a change of condition. Resident #1 called an outside person (Witness 2) to request emergency services. Resident #1 was transported to the hospital and was admitted. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,400,,,Neglect +DA133625A,70M030,ALF,6/21/2013,"The facility failed to conduct a facility investigation on a report by Resident #1 that a resident-to-resident incident involving Resident #2 had occurred. Resident #2 had known behaviors and his/her service plan called for staff to intervene when his/her behavior became aggressive, and to notify facility staff and medical personnel ""immediately."" The facility's failures are a violation of Oregon Administrative Rules.",2,,,, +DA133625B,70M030,ALF,6/21/2013,The facility failed to have medication available for Resident #2's scheduled medication. He/she was not administered medication on 6/1/13. The failure is a violation of Oregon Administrative Rules.,2,,,, +DA135100,70M030,ALF,11/15/2013,"Resident #1 had a known condition of urinating a lot. The facility failed to provide adequate incontinence care to Resident #1, who was often found sitting in wet undergarments. The facility's failure is a violation of Oregon Administrative Rules.",2,,,, +MV121467,70M030,ALF,10/5/2012,"The facility failed to ensure timely staff assistance to provide toileting for Resident #1. Due to the untimely wait for assistance, Resident #1 experienced falls of which three of them resulted in hospitalizations. His/her care plan specifies that he/she should wait for assistance to use the bathroom. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +The Notification of Findings was completed at a later date; therefore a civil penalty was not issued due to the extended period of time between the incident date and processing by the Department.",3,,,,Neglect +MV135030B,70M030,ALF,11/4/2013,"Resident #1's ring went missing. An unknown individual is responsible for the theft of his/her ring, constituting abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV133106,70M030,ALF,4/4/2013,"Resident #1 had physician treatment orders for non-adhesive bandages to be used for wound care dressing. Facility staff used adhesive tape to dress his/her wound which caused additional skin tears. The facility failed to provide wound care services as specified in the physician's treatment orders. This failure constitutes abuse, is considered neglect of care, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MV135110,70M030,ALF,10/14/2013,"The facility failed to timely respond to Resident #1's call light resulting in continued pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV146697,70M030,ALF,4/9/2014,Resident #1 dispensed his/her own medications until 3/18/14 when the facility took responsibility. There have been several mistakes in medications since the facility took over. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,,,, +DA146443,70M030,ALF,3/19/2014,"Resident #1 reported money missing from his/her purse and was not located upon a search of his/her room. An unknown individual is responsible for the theft of money, constituting financial exploitation. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA147696,70M030,ALF,7/9/2014,"The facility failed to take reasonable precautions, failed to follow facility policy and procedures, and failed to intervene when Resident #1 experienced a medical emergency. Resident #1 was transported to the hospital and ultimately died. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",4,400,,,Neglect +DA146720,70M030,ALF,4/10/2014,"Resident #1 experienced a significant change of condition related to weight loss. The facility failed to assess and intervene, monitor, and follow his/her care plan. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA146725,70M030,ALF,4/14/2014,"The facility failed to ensure Resident #1's TED hose were put on properly as ordered by his/her physician. The TED hose rolled down his/her legs and caused Resident #1 pain. The facility's failure is a violation of resident rights, is considered neglect of pain and constitutes abuse.",2,,,,Neglect +DA146795A,70M030,ALF,4/14/2014,"The facility failed to ensure Resident #1's medication was administered as ordered resulting in diarrhea and abdominal discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +DA146795B,70M030,ALF,4/14/2014,Resident #1 reported approximately $20 missing from his/her room. An unknown individual is responsible for the loss of his/her money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +DA148673,70M030,ALF,9/18/2014,The facility failed to respond timely to Resident #1's call for assistance for his/her toileting needs. The failure is a violation of Oregon Administrative Rules.,2,,,, +DA146992,70M030,ALF,4/29/2014,Resident #1 discovered approximately $80 missing from his/her wallet; however his/her wallet was found in the laundry and returned. An unknown person is responsible for the theft of Resident #1's money. The facility failed to ensure a safe environment and the failure is a violation of Oregon Administrative Rules.,2,,,,Financial abuse +DA147538,70M030,ALF,6/10/2014,Resident #1 did not receive his/her medication as ordered exposing him/her to potential harm. The facility failed to provide a safe medication administration system and the failure violates Oregon Administrative Rules.,2,,,, +CO15156,70M030,ALF,8/6/2015,"The facility failed to evaluate and monitor, and ensure a Registered Nurse assessed and documented findings for Resident #1 when he/she experienced a change of condition and safety issues. Resident #1 experienced significant weight loss and continued to lose weight. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA148626,70M030,ALF,8/29/2014,Resident #1 required assistance with his/her colostomy bag. He/she had an instance when the colostomy bag needed to be emptied and no staff were located for an extended period of time resulting in the bag filling to capacity. The facility failed to appropriately provide assistance. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +DA153476,70M030,ALF,11/3/2015,"The facility failed to assess and intervene when Resident #2 exhibited signs of increased frustration with Resident #1. Resident #2 was observed to force feed Resident #1 and then slap Resident #1 in the face. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +OR0001002002,70M030,ALF,9/10/2015,,0,,,Substantiated, +OR0001023201,70M030,ALF,10/29/2015,,1,,,Substantiated, +BH117821,70M031,ALF,8/5/2011,"The facility kept multiple residents' funds in an unlocked file cabinet located in the front office. Funds totaling more than $1400 were discovered missing between August 5 and August 6, 2011. The facility failed to provide a safe environment resulting in the loss of residents_x001A_ funds. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +BH145905,70M031,ALF,1/22/2014,A large amount of medications were found in the garbage can at the facility. Eight residents were not administered their medications. Reported Perpetrator 2 (RP2) was responsible for administering the medications. RP2 was determined to be responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,3,,Not Substantiated,Substantiated,Neglect +BH150102,70M031,ALF,12/24/2014,Resident #1 was out with family and returned to the facility around 10:00 pm. Staff had already discarded his/her evening medication. Staff eventually dispensed Resident #1's medication due to Resident #1 experiencing anxiety. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH135445,70M032,ALF,2/22/2013,"Resident #1 had narcotic pain medication stolen out of his/her room. This medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +JG132672,70M033,ALF,2/20/2013,"Resident #1 had money and narcotic medication taken from a locked drawer in his/her apartment on two separate occasions. The locked drawer was broken into. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the items, which is considered financial exploitation and is considered abuse.",2,,Not Substantiated,Substantiated,Financial abuse +JG145626B,70M033,ALF,8/27/2012,Resident #1 had an order for pain medication decreased from three times daily to two times daily. Reported Perpetrator #2 accidently administered pain medication three times to Resident #1 despite the recent change. Resident #1 did not suffer any ill effects. The facility failed to ensure a safe medication administration system. This failure is a violation of Oregon Administrative Rules.,2,,,, +JG145890,70M033,ALF,11/27/2013,Resident #1 did not receive his/her vitamin or supplement as prescribed. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +JG148243C,70M033,ALF,6/26/2014,Resident #1 appeared with bruising on his/her hands. The bruising is believed to have been caused by improper transfers. Resident 1#'s care plan was updated to reflect that he/she is now a two-person transfer. Staff received training on proper transfer techniques. The facility failed to appropriately transfer Resident #1 causing bruising. The failure is a violation of Oregon Administrative Rules.,2,,,, +JG148243A,70M033,ALF,6/26/2014,Resident #1 was placed on a strict two hour toileting schedule by the facility. He/she was only allowed to be toileted outside the two hour schedule if he/she was wet. The facility had no order from Resident #1_x001A_s physician dictating the two hour toileting schedule. This schedule caused Resident #1 anxiety and incontinence issues. The facility failed to obtain a physician_x001A_s order for Resident #1 or assure Resident #1_x001A_s resident rights. The failures are a violation of Oregon Administrative Rules.,2,,,, +JG134209,70M033,ALF,6/24/2013,Resident #1 was removing food from the dining room of the facility. Reported Perpetrator 2 (RP2) confronted Resident #1 stating that he/she was not allowed to remove food from the dining room. RP2 attempted to remove the food from Resident #1's hand. The facility failed to assure Resident #1's resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +JG134405A,70M033,ALF,7/2/2013,Resident #1 was sitting at the reception desk at the facility. Reported Perpetrator 2 (RP2) told Resident #1 he/she could not sit there. RP2 pushed the chair with Resident #1 sitting in it out into the lobby area. This happened twice and then RP2 took the chair and began walking away. Resident #1 then tried to grab the chair back. During this exchange RP2 swung his/her arm back making contact with Resident #1's chin as seen in surveillance video. Resident #1 had no evidence of bruising but stated that it caused sensitivity to his/her teeth. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +JG153747,70M033,ALF,9/22/2015,"Resident #1 and Resident #2 reported money missing in the range of $500.00 to $1,400.00 from the lock box in their room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH117537,70M034,ALF,7/20/2011,The facility failed to provide a safe environment resulting in the loss of at least three residents' narcotic medications from their rooms. An unknown individual was apportioned abuse.,3,0,Not Substantiated,Substantiated,Financial abuse +BH118140,70M034,ALF,8/8/2011,RP2 asked for and received money from Resident #1. RP2 no longer is employed at the facility. The facility failed to provide a safe environment resulting in the loss of resident money. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +BH118781B,70M034,ALF,8/31/2011,The facility failed to immediately report suspected abuse after Resident #1 claimed RP2 was sexually inappropriate with her/his. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB133660,70M035,ALF,7/2/2013,"Resident #1 had $40.00 in his/her wallet in a locked drawer. Resident #1 asked Witness #1 to access the money for him/her while visiting. Witness #1 reported there was only $2.00 left in the wallet. Resident #1 had the key to the drawer on the same key ring as a locked drawer with personal care items, which facility staff had to access to assist Resident #1. Resident #1 did not always see staff while they were accessing the drawer. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took Resdient#1's money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB135396,70M035,ALF,12/16/2013,"Reported Perpatrator 2 (RP2) and Reported Perpetrator 3 (RP3) tied Resident #1's pant legs together at the hem, and tied a scarf around Resident #1's waist to keep Resident #1 from accessing his/her protective undergarment. These restraints left red marks and made it so Resident #1 could not move their legs. RP2 and RP3 are responsible for the inproper use of a restraint which constitutes abuse. The facility failed to ensure Resident #1's care plan was followed which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Restraints +HB147669,70M035,ALF,7/8/2014,"It was discovered that Resident #1 had approximately $97 missing from his/her locked drawer. An unknown individual is responsible for the theft of money, which is considered financial exploitation. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC118530B,70M036,ALF,11/22/2011,Resident #1 required being seen by her/his physician prior to getting her/his medication refilled. The facility failed to ensure physician services resulting in the resident not getting medication as ordered. There was no observable harm as a result.,1,0,,, +BC134801,70M036,ALF,10/20/2013,RP2 and Resident #1 engaged in a verbal confrontation. Witness testimony and facility documentation revealed RP2 was unprofessional in handling her/his conversation with Resident #1. The facility failed to ensure Resident #1 was treated with respect and dignity and is a violation of Oregon Administrative Rules.,2,,,, +BC149127,70M036,ALF,11/1/2014,"Resident #1 was given another resident's medication during medication pass. Resident #1 was transported to the hospital where additional medical issues were found that resulted in being admitted. Witness testimony revealed the medication cups were labeled with residents' first name only. The facility failed to ensure a safe medication system resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC150135,70M036,ALF,1/14/2015,"Resident #1 reported theft of jewelry from her/his room. Investigative details revealed that there were increased strangers wandering the building. There was no known plan to address safety. The facility failed to ensure a safe environment resulting in the loss of resident property. An unknown person was also found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +BC151315,70M036,ALF,5/15/2015,"Resident #1 was new to the facility and was administered the wrong medications. The facility failed to ensure a safe medication administration system resulting in Resident #1 being transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC153108,70M036,ALF,10/5/2015,The facility failed to ensure a safe environment resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +HB132237,70M037,ALF,1/24/2013,"Resident #1 discovered that he/she was missing his/her wedding ring and his/her spouse's ring. During the course of the investigation, it was discovered that Reported Perpetrator 2 (RP2) had stated something about shoplifting to other staff; however RP2 did not admit to taking the rings. There was not enough evidence that identified a concrete suspect. As a result, an unknown individual is responsible for the theft of rings which constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +HB133880,70M037,ALF,7/23/2013,"Reported Perpetrator 2 (RP2) took Resident #1's pain medication and replaced it with Tylenol. Resident #1 was taking the medication as needed (PRN), following a surgery. It is not known how many dosages Resident #1 missed. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. RP2 is responsible for wrongfully taking Resident #1's medications, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB134086,70M037,ALF,8/5/2013,"Resident #1 received eight new sweaters as a gift from his/her family, which were valued at over $300.00 total. Shortly after receiving the sweaters, they were taken from Resident #1's apartment. Resident #1 locks his/her apartment door but often finds it unlocked when returning. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. An unknown person is responsible for taking the sweaters, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB148118,70M037,ALF,8/13/2014,"Resident #1 had a regimented schedule, went outside often, and was care planned for two hour checks. On 7/11/14 at approximately 8:00pm, Resident #1 was found outside where he/she had fallen that resulted in broken ribs. The facility doors were set to lock about 8:30pm; however facility staff were aware that the doors were locking around 6:00pm. The facility failed to follow Resident #1's care plan and failed to take reasonable precautions to provide a safe environment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB153565X,70M037,ALF,11/10/2015,The facility failed to ensure Reported Perpetrator 2 (RP2) treated Resident #1 with dignity and respect. The failure is a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +RD116412B,70M038,ALF,1/27/2011,Resident #1 was noted in his/her care plan to become verbally aggressive with staff and call names; however staff had interventions to remove themselves from the situation and ask for assistance. Reported Perpetrator 2 (RP2) and Resident #1 argued during a transfer.,2,0,,, +RD116791,70M038,ALF,3/15/2011,"The facility failed to properly plan care, document, and provide clear direction and description to staff regarding Resident #1's wrist brace. Staff were providing assistance with the wrist brace; however there was no written physician order for this treatment, no staff training, and neither the administrator or nurse were aware of the brace. Resident #1 suffered unreasonable discomfort when his/her finger was found under the brace.",2,0,,,Neglect +RD116835,70M038,ALF,3/23/2011,"Resident #1 was not visually observed by staff to ingest his/her morning medications the week of March 14-18, 2011. Various morning medications were found scattered around his/her room.",2,0,,, +RD117347,70M038,ALF,5/18/2011,Reported Perpetrator 2 spoke disrespectfully to Resident #1 when arguing over the correct eye drop medication.,2,0,,, +RD117705,70M038,ALF,7/25/2011,"Upon returning from four days out of the facility, Resident #1 discovered money missing from his/her wallet that had sentimental value from a deceased loved one. Facility staff had key access to his/her room; however deny taking the money. The theft occurred by actions of an unknown individual.",2,0,Not Substantiated,Substantiated,Financial abuse +RD118052,70M038,ALF,8/16/2011,The facility failed to provide a safe environment resulting in the loss of resident's wallet containing $100. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +RD118149,70M038,ALF,9/17/2011,The facility failed to provide a safe environment resulting in the loss of Resident #1's envelope containing money. An unknown individual was responsible for the loss of money.,2,0,Not Substantiated,Substantiated,Financial abuse +RD129919,70M038,ALF,3/23/2012,Resident #1 was service planned to receive thickened liquids and pureed foods. Reported Perpetrator 2 (RP2) gave him/her water that was not thickened. Resident #1 was transported to the hospital and determined to have aspirated. RP2 was found responsible for abuse. The facility failed to assure Resident #1_x001A_s service plan was being followed. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Neglect +CO12133,70M038,ALF,10/4/2012,"The facility failed to ensure reasonable precautions were taken, and failed to monitor, evaluate, and update the service plan for Resident #2 who eloped from the building and wandered into other residents_x001A_ rooms. Resident #2 eloped, fell and sustained injuries. The facility failed to ensure an RN assessment was completed for Resident #1_x001A_s significant change of condition related to health status. Resident #1 had decreased oxygen saturation levels, decreased ability to eat, ongoing complaints of pain and increased behaviors. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +RD135282,70M038,ALF,12/2/2013,"The Facility failed to protect Resident #1 from theft of money resulting in three (3) incidents of missing money between August and December 2013 totaling approximately $500. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation which constitutes abuse.",3,300,,,Financial abuse +RD146140,70M038,ALF,2/9/2014,"Resident #1 had $240 go missing in October 2013. The money was taken by an unknown individual and this person is responsible for theft of property, is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD146785,70M038,ALF,4/3/2014,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe environment for Resident #1. This failure is a violation Oregon Administrative Rules.",2,300,Not Substantiated,Substantiated,Financial abuse +RD146781,70M038,ALF,3/27/2014,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD147576,70M038,ALF,5/3/2014,"Resident #1 had several items go missing out of his/her bag. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD151674,70M038,ALF,5/30/2015,"Resident #1 and Resident #2 had medication go missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +RD153674,70M038,ALF,11/17/2015,"The facility failed to adequately monitor Resident #1 and Resident #3. Resident #1 and Resident #3 got into a physical altercation, but no injuries were incurred. This failure is a violation of Oregon Administrative Rules.",2,,,, +RD154021,70M038,ALF,12/21/2015,"The facility failed to fill Resident #1's eye drop prescription in a timely manner. Resident #1 went several days without eye drops and experienced increased pain in his/her eyes. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +OR0001006400,70M038,ALF,9/21/2015,,1,,Not Substantiated,Substantiated, +OR0001006401,70M038,ALF,9/21/2015,,1,,Not Substantiated,Substantiated, +OR0001006402,70M038,ALF,9/21/2015,,1,,Not Substantiated,Substantiated, +OR0001007901,70M038,ALF,9/24/2015,,0,,Not Substantiated,Substantiated, +NB105209,70M039,ALF,9/7/2010,A resident of the Facility experienced a loss of his/her personal resources when it was discovered that he/she was missing money from his/her room at the Facility. The Facility investigation was not able to determine who was responsible for the missing money.,2,0,,, +NB105214,70M039,ALF,9/9/2010,A resident of the Facility experienced a loss of his/her personal resources when it was discovered that he/she was missing money from his/her room at the Facility. The resident's money was not located.,2,0,,, +NB105820,70M039,ALF,11/23/2010,"A Facility staff member, Reported Perpetrator #2, forged a check belonging to a Facility resident and cashed it. The check was associated with a closed bank account. A law enforcement investigation determined the writer of the check was most likely not the resident, as his/her check samples did not match his/her writing style. RP2 admitted to cashing the check",2,0,Not Substantiated,Substantiated,Financial abuse +NB116837,70M039,ALF,4/24/2011,A resident of the Facility was the recipient of unwanted sexual contact by another Facility resident. The resident had previously displayed behaviors regarding inappropriate sexual behaviors and was being monitored on an hourly basis; however he/she was still able to make inappropriate contact with the other resident.,2,0,,, +NB117227,70M039,ALF,6/6/2011,Resident #1 had symptoms of an upper respiratory infection; and his/her physician ordered that he/she be taken to the emergency room if his/her fever was 100 degrees or higher. Reported Perpetrator 2 (RP2) did not document the orders; resulting in the orders not being followed and Resident #1 not transported as ordered.,3,0,Not Substantiated,Substantiated,Neglect +NB116792,70M039,ALF,4/20/2011,"Resident #1 attempted to have sexual contact and inappropriately touched residents of the opposite gender in the facility, some with cognitive impairments. Witness testimony and facility documentation revealed Resident #1 was not cognitively impaired and had sexual contact with Resident #2; and inappropriately sexually touched Resident #3 and Resident #7. The Facility failed to provide interventions and care plan for Resident #1_x001A_s behavior resulting in an unsafe environment for all other residents. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute sexual abuse.",3,2500,,,Sexual abuse +NB129216A,70M039,ALF,1/23/2012,The facility admitted Resident #1 while attempting to determine if he/she was appropriate for the facility. The facility failed to ensure adequate screening was completed to determine that the facility was able to meet the needs of Resident #1 prior to admitting. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB129216B,70M039,ALF,1/23/2012,The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving medications according to physician_x001A_s orders. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NB129669,70M039,ALF,4/3/2012,"Resident #1 has had eight falls in the facility between December 2, 2010 and February 28, 2012, some with injury, with no amendments to his/her care plan. The facility failed to update Resident #1_x001A_s care plan to address falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NB120924,70M039,ALF,8/29/2012,Resident #1 reported his/her medication missing. Resident #2 and #3 both reported rings missing. Resident #4 reported check books missing and Resident #5 reported two missing checks from a check book. The thefts resulted from an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +NB132245,70M039,ALF,1/28/2013,"Resident #1 was administered another resident_x001A_s medications. The error was discovered immediately and Resident #1 was transported to the hospital, treated and released back to the facility the same day. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +NB134562,70M039,ALF,9/25/2013,Resident #1 was discharged from the facility with Resident #2_x001A_s medications instead of his/her medications. Resident #1 went without four of his/her medications for one medication pass. Resident #2 did not go without any of his/her medications. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB148319B,70M039,ALF,8/12/2014,Resident #1 had an order for eyedrops to be given twice daily. Review of facility records revealed that the resident was not receiving eyedrops as ordered. The facility failed to administer medication as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB150844,70M039,ALF,4/8/2015,"The facility failed to provide a safe medication administration system resulting in Resident #1 being transported to the hospital for treatment. Facility records revealed Resident #1 was administered twice the prescribed dose of Coumadin for several days. Facility failed to keep an accurate Medication Administration Record (MAR). The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HM128838,70M040,ALF,12/1/2011,"Resident #1 and Resident #2 both reported missing money from their respective rooms and RP2 was suspected of the theft. Internal investigation was initiated and local law enforcement called, however it was unable to be determined who was responsible for the thefts. An unkown person was found responsible for abuse. The facility failed to provide a safe environment resulting in the loss of money from two residents' rooms.",2,0,Not Substantiated,Substantiated,Financial abuse +HM129205,70M040,ALF,1/26/2012,"Three residents reported missing money. Resident #1 had $61.00 missing from her/his wallet and was able to recall specific details. Resident #2 was unable to provide any additional information and Witness #1 was unsure if money missing or stolen. Resident #3's wallet that may have contained $70.00 went missing, however resident unsure of when it went missing. Resident #3 later reported finding $41.00. The facility failed to provide a safe environment resulting in the loss of $61.00 from Resident #1. Investigation was unable to determine if Resident #2 and Resident #3's money was lost or stolen. An unknown individual was found responsible for theft.",2,0,Not Substantiated,Substantiated,Financial abuse +HM129486,70M040,ALF,3/8/2012,Resident #1 had approximately $30 missing from her/his wallet that was located in her/his room. There have been an increase in thefts from residents in the past few months and no suspects have been identified. The facility failed to provide a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for financial abuse.,2,300,Not Substantiated,Substantiated,Financial abuse +HM129463A,70M040,ALF,2/13/2012,"It was reported that $150 was missing from Resident #1's wallet. Investigation was initiated, but was unable to determine any suspects. The facility failed to provide a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for financial abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +HM129608,70M040,ALF,3/14/2012,"On March 14, 2012, Resident #1 discovered $70.00 missing from a zippered hood pouch of her/his jacket. Resident #2 had a wallet go missing containing approximately $12.00 in January 2012. On March 15, 2012, the wallet was discovered in a drawer in the tub room without the $12.00. Resident #2 does not used the tub room. The facility failed to provide a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for finanical abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +HM129609,70M040,ALF,3/19/2012,"Resident #1 reported $500 missing from the personal safe in her/his room. Upon investigating, it was discovered that the locked safe could be opened without a key. The facility failed to provide a safe environment. An unknown person was held responsible for financial abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +HM129692,70M040,ALF,4/4/2012,"A wallet containing $50 in cash, credit cards and checks was taken from Resident #1's dresser drawer. There have been multiple recent reports of theft from residents with no identified suspects. The facility failed to provide a safe environment resulting in a loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for financial abuse.",2,250,Not Substantiated,Substantiated,Financial abuse +HM120086,70M040,ALF,4/26/2012,"Resident #1 reported a wallet containing several items including a bank card, social security card and identification card missing from her/his room. There have been multiple thefts from residents in the past few months and no suspects have been identified. The facility failed to provide a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for financial exploitation.",2,300,Not Substantiated,Substantiated,Financial abuse +HM121146,70M040,ALF,8/14/2012,"The facility failed to ensure a safe environment resulting in the loss of money from Resident #1's wallet located in her/his room. The failure is violation of Oregon Administrative Rules. An unknown individual was held responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +HM121802,70M040,ALF,11/17/2012,Resident #1 was administered another resident's medication and incorrectly documented a blood draw that did not occur. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Ruels.,2,0,,, +HM133181,70M040,ALF,4/14/2013,"Resident #1 reported Resident #2 touched him/her in a sexually inappropriate manner and stated it happened before. Witnesses stated sexually inappropriate behavior was an ongoing issue with Resident #2. The facility failed to protect Resident #1 from inappropriate sexual contact. The failure is a violation of resident's rights, is considered neglect and constitutes abuse.",3,2500,Substantiated,Substantiated,Neglect +HM133554,70M040,ALF,5/6/2013,"Resident #1 had money taken from his/her apartment. Although witnesses stated they believed it could be Reported Perpetrator 2; there was no evidence to support that allegation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the money, which is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HM146606,70M040,ALF,3/7/2014,"Residents # 1,2,3, and 4 had medication stolen. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Residents #1,2,3, and 4 from property theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HM149519,70M040,ALF,11/25/2014,"The facility failed to have labs drawn for Resident #1 as required by a physician_x001A_s treatment order. Resident #1 required hospital treatment for a condition that was to be monitored by drawing these labs. This failure is a violation of Resident Rights, is considered neglect of care, and constitutes abuse.",3,300,,, +NW120696,70M041,ALF,5/20/2012,"Resident #1 was a one-person assist; however he/she required more than a one-person assist after falling and fracturing his/her right shoulder. He/she was in constant pain. The facility failed to update Resident #1_x001A_s care plan after the change of condition and implement new interventions or increase staffing levels. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NW120734,70M041,ALF,5/18/2012,"Resident #1 was admitted to the facility as a two-person transfer, and required assistance of a mechanical lift for all transfers and repositioning; however the facility only provided two-person staffing levels at shift change. On May 19, 2012, Resident #1 was assisted by one caregiver and fell sustaining a right Fibular Shaft fracture. The facility failed to follow Resident #1_x001A_s care plan and failed to provide appropriate staffing levels. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH116221,70M042,ALF,12/25/2010,"A resident of the Facility experienced a loss of his/her diamond necklace. It was worn by the resident the night before he/she reported it missing to staff. He/she was assisted with removing the necklace by Facility staff and it was placed on his/her dresser. Upon waking, the necklace was missing.",2,0,,,Financial abuse +BH120635A,70M042,ALF,6/30/2012,Resident #1 felt RP2 was disrespectful while providing care to the resident. The facility failed to ensure resident rights resulting in loss of dignity. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH132833,70M042,ALF,3/30/2013,"Residents #1 and #2 were missing money from their apartments. Facility security cameras revealed Reported Perpetrator 2 (RP2) taking money from resident's rooms. Facility staff stated RP2 admitted to taking the money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules. RP2 is found responsible for theft, constituting abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BH153123,70M042,ALF,9/25/2015,The facility failed to ensure Resident #1 was treated with respect and dignity by Reported Perpetrator 2 (RP2). The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +CO16011,70M042,ALF,12/18/2015,"The Assisted Living Facility re-licensure survey completed on December 18, 2015, incorporated into this notice by reference, substantiated the following: + + + +The facility failed to provide health services and to ensure an RN assessment was completed in response to Resident #1_x001A_s significant change of condition. Resident #1 experienced continued, significant weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NB116220,70M044,ALF,1/24/2011,"The Facility failed to provide a safe environment for Resident #1. The Facility failed to ensure appropriate nursing for Resident #1 when he/she experienced a significant change to his/her condition. Facility administration lacked a comprehensive knowledge of administrative rule, which resulted in Facility investigations related to falls and injuries not taking place.",4,400,,,Neglect +NB116869,70M044,ALF,4/27/2011,The facility failed to provide a safe environment resulting in the loss of money from residents' rooms. RP3 was apportioned abuse.,3,0,Not Substantiated,Substantiated,Financial abuse +NB118171,70M044,ALF,10/7/2011,"Resident #1 reported $67 missing from wallet. RP2 was suspected of taking the money, but investigative findings were unable to determine who took the money. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown individual was apportioned abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +NB129485,70M044,ALF,1/26/2012,"On March 11, 2012, Resident #1 reported missing $170 from her/his wallet. During the course of the investigation, it was discovered that RP2 borrowed $500 from Resident #1 on or about January 27, 2012. RP2 requested an additional $50 a few days later. RP2 admitted to borrowing $550 from Resident #1 but denied taking $170 from the wallet. Resident #1 was not reimbursed at the close of the investigation. The facility failed to provide a safe environment resulting in Resident #1 being finanical exploited by RP2. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for financial exploitation and constitutes abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +NB120152,70M044,ALF,5/30/2012,"Resident #1 was a new resident that required catheter care as ordered by her/his physician. Resident #1 was also discovered with skin breakdown on her/his heels and bottom. The facility was not providing appropriate catheter care. The facility failed to appropriately plan care and follow physician's orders. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +NB146249,70M044,ALF,3/2/2014,The facility failed to ensure the service plan was followed resulting in Resident #1 not receiving her/his scheduled shower that day. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS105192,70M045,ALF,12/15/2009,"The Facility failed to appropriately assess and intervene with respect to Resident #1_x001A_s fall risk. The resident suffered numerous falls that resulted in injury. The resident_x001A_s final fall at the Facility resulted in being sent to the hospital, where it was determined the resident had suffered a fractured hip.",3,300,,,Neglect +MS116181A,70M045,ALF,12/19/2010,"A resident of the Facility whose condition was declining did not receive adequate enough supervision to ensure the resident's safety, resulting in falls.",2,0,,,Neglect +MS116181B,70M045,ALF,12/19/2010,"A resident of the Facility was observed to have not been showered or have his/her clothes changed for one week. Facility staff documented when the resident refused assistance with showering, but that documentation showed that staff did not offer a shower to the resident during the period in question.",1,0,,, +MS129227A,70M045,ALF,1/12/2012,"Witness #6 ordered Resident #1 to be given a laxative medication every hour until he/she had a bowel movement. The medication was given hourly between 6 PM and 10 PM. After 10PM the medication was not given and there was no documentation that he/she had a bowel movement. The facility failed to administer an ordered medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,, +MS129227B,70M045,ALF,1/12/2012,The facility was not able to accommodate the needs of Resident #1 when he/she was discharged from the hospital. The facility failed to provide adequate care to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS129459,70M045,ALF,3/3/2012,"Resident #1 fell and sustained a cut to the head; a skin tear on his/her knee and pain in shoulder and groin area. Witness #2 was contacted and told the caregivers to wait until morning to reassess Resident #1. Emergency services were notified in the morning and Resident #1 was transported to the hospital. Resident #1 had a hip fracture. The facility failed to obtain timely medical treatment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS120058A,70M045,ALF,5/5/2012,"Resident #1 needed his/her PRN pain medication administered. He/she could not get a response from the call light and could not find a care giver when he/she went to find someone to assist him/her. The facility failed to administer Resident #1_x001A_s PRN medication when needed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS120058B,70M045,ALF,5/5/2012,Reported Perpetrator 2 (RP2) administered Resident #1 the wrong blood sugar medication pen. Resident #1 was given 35 units of blood sugar medication instead of 2 units. RP2 notified the facility RN and called 911. Resident #1 was treated by the EMTs and was then transported to the hospital for observation. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Neglect +MS147192,70M045,ALF,5/17/2014,"Resident #1 has a history of resisting care and is care planed for staff to re-approach until he/she is less combative. Resident #1 was resisting care and Reported Perpetrator #2 climbed on top of Resident #1 in order to continue to provide care. Resident #1 grabbed Reported Perpetrator #2's lanyard and incurred a bruise to his/her hand when care staff removed the lanyard from his/her grasp. Reported perpetrator #2 is responsible for neglect of care, which constitutes abuse. The facility failed to protect Resident #1 from rough treatment.",2,,Not Substantiated,Substantiated,Neglect +ES116860,70M048,ALF,4/26/2011,Resident #1 is a two person transfer. RP2 has previously worked with Resident #1 and was directed on how to properly transfer Resident #1. RP2 improperly transferred Resident #1 resulting in bruising. RP2 was substantiated for abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +ES117361,70M048,ALF,6/26/2011,RP2 was observed being verbally inappropriate after Resident #1 continued to pull the call cord for assistance. The facility ultimately terminated RP2's employment. The facility failed to ensure Resident #1 was treated with respect and dignity. The failure is a violation of resident rights.,2,0,,, +ES117356A,70M048,ALF,6/26/2011,Facility staff failed to appropriately transfer Resident #1 resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +ES117356B,70M048,ALF,6/26/2011,RP2 was observed to be verbally inappropriate with Resident #1. The facility failed to assure resident rights and is a violation of OARs.,2,0,,, +ES134530A,70M048,ALF,9/6/2013,Reported Perpetrator 2 (RP2) was witnessed multiple times being rough and impatient with Resident #1 during transfers. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +ES134530C,70M048,ALF,9/6/2013,Reported Perpetrator 2 (RP2) was witnessed taking Resident #1_x001A_s meal tray away from him/her. Resident #1 said he/she was not done. The facility failed to .assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES147146,70M048,ALF,5/20/2014,Resident #1 has failed to follow managed risk agreements regarding smoking safely. He/she smokes while wearing oxygen around other residents. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES151322,70M048,ALF,5/13/2015,One hundred pills of anti-anxiety medication belonging to Resident #1 came up missing from Witness 3's office. An unknown individual was found responsible for the loss of Resident #1's medications which constitutes financial exploitation. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +OR0001029100,70M048,ALF,11/12/2015,,0,,Not Substantiated,Substantiated, +OR0001029101,70M048,ALF,11/12/2015,,0,,Not Substantiated,Substantiated, +PT151263,70M049,ALF,4/12/2015,The facility failed to adequately care plan for altercations between Resident #1 and Resident #2. The residents had a history of aggression towards each other at another location. The facility failed to care plan for this when the residents were admitted. Resident #1 and Resident #2 were involved in an altercation at the facility. This failure is a violation of Oregon Administrative Rules.,2,,,, +PT151888,70M049,ALF,7/2/2015,The facility failed to provide Resident #1 lunch prior to a medical appointment. This failure is a violation of Oregon Administrative Rules.,2,,,, +TM129173,70M050,ALF,1/31/2012,RP2 administered Resident #1 another resident's medication resulting in transportation to the hospital for treatment. The facility failed to ensure medications were administered as ordered. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for abuse.,3,0,Not Substantiated,Substantiated,Neglect +MV120053,70M051,ALF,5/12/2012,"Resident #1 was a known fall risk that required two person assist and care planned for staff to check frequently. On the evening of May 12, 2012, Resident #1 fell in her/his room and was not found until the following morning. Witness testimony revealed Resident #1 was not checked on all night. Resident #1 was transported to the hospital for treatment of a wound that required 15 stitches. The facility failed to follow Resident #1_x001A_s care plan resulting in moderate harm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV116678,70M052,ALF,4/2/2011,"Three Facility residents indicated they had been physically mishandled by a Facility staff member, Reported Perpetrator #2 (RP2). One resident was hit by RP2 and another reported being pushed while walking down a hall. RP2 was known by his/her peers as well as management to be short with residents at times, and had been previously spoken to about that issue.",2,0,Substantiated,Substantiated,Physical Abuse +MV120721,70M052,ALF,7/14/2012,"Reported Perpetrator 2 (RP2) took Resident #1's credit card and made personal purchases, which constitutes abuse. The facility failed to protect Resident #1 from theft. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +NW129326,70M053,ALF,1/27/2012,"Resident #1 was on hospice for end of life care and had ordered medications to treat pain. On Friday, January 27, 2012 Resident #1 was in pain and did not receive any pain medications. RP2 had Resident #1 transported in the late afternoon by facility bus to a nursing facility in another town without appropriate hospice coverage. Resident #1 was observed to be in significant pain and passed away the following day. The facility failed to provide appropriate care resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Both the RP2 and the facility are held responsible for abuse.",4,400,Substantiated,Substantiated,Neglect +NW117716,70M053,ALF,6/7/2011,"Resident #1 had a diagnosis related to memory loss and resided in a locked facility. On or about June 7, 2011, Resident #1 was discovered missing and a search was started, but ended 45 minutes later after staff thought they determined Resident #1's wherabouts. A search was later resumed and Resident #1 was found outside approximately 22 hours later where she/he was transported and treated for hypothermia. The facility failed to ensure a safe environment resulting in harm and the potential for serious harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to the extended period of time between the investigation and processing by the Department.",3,0,,,Neglect +NW120500,70M053,ALF,3/23/2012,The facility failed to administer medication as ordered resulting in the potential for harm. The facility also failed to provide access to facility and resident records. The failure is a violation of Oregon Administrative Rules.,2,0,,, +NW120904,70M053,ALF,6/28/2012,"Resident #1 required total assist with ADL (Activities of Daily Living) and wound care. Resident #1 developed a decubitus wound on the coccyx that required staff service and monitoring. The facility failed to appropriately monitor, update the service plan and provide assistance as Home Health directed, contributing to the worsening of a decubitus ulcer. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NW121407,70M053,ALF,8/28/2012,"Resident #1 was incontinent, required toileting assistance and care planned for night staff to wake her/him up to use the restroom a couple of times at night. The facility staff did not following the care plan and failed to answer Resident #1's call light in a timely manner resulting in incontinence. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility also failed to provide facility documentation upon request.",2,0,,,Neglect +NW121406,70M053,ALF,9/1/2012,"Resident #1 had a routine for coming down to breakfast approximately the same time everyday. Resident #1 did not routinely eat in the dining room for lunch or dinner. On September 1, 2012, Resident #1 did not come down for breakfast as usual. A staff member found Resident #1 on the floor at 11:15 am. Resident #1 indicated she/he fell on the floor the night before and was transported to the hospital for treatment. The facility failed to timely assure a resident was safe after Resident #1 did not come down for breakfast resulting in continued pain and suffering.",2,0,,,Neglect +NW121408,70M053,ALF,8/23/2012,"A review of narcotic books after researching two medication errors discovered RP2 signed out multiple narcotics on several narcotic cards using the same date and time over a two month period. The facility failed to provide a safe medication administration system resulting in the theft of multiple narcotics from two different residents. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. The facility also failed to keep and provide residents' records as required. RP2 was held responsible for financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +NW121793,70M053,ALF,8/31/2012,"Resident #1 had an order for a mechanical soft diet and honey thick liquids that were documented on her/his service plan. Witness testimony revealed the facility was not providing a mechanical soft diet or honey thick liquids. On August 31, 2012, Resident #1 was transported to the hospital for respiratory distress and diagnosed with aspiration pneumonitis. The facility failed to follow physician_x001A_s order or appropriately monitor resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility also failed to cooperate with an investigation. The failure is a violation of Oregon Administrative Rules.",3,300,,,Neglect +NW121927,70M053,ALF,9/20/2012,"Resident #1 had orders and was care planned for total assist with oxygen administration. Resident #1 experienced multiple nose bleeds. The facility failed to assist Resident #1 with maintaining oxygen equipment and providing administration assistance. The facility also failed to assess and intervene after Resident #1 continued to experience nose bleeds. The failures are violations of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide requested documentation. The failure is a violation of Oregon Administrative Rules.",3,300,,,Neglect +CO13008,70M053,ALF,1/25/2013,See License Condition for details (ALFCP13-001),3,0,,,Neglect +NW132703,70M053,ALF,1/14/2013,"RP2 was observed being rough including spraying cold water on Resident #1 while providing shower care. Resident #1 expressed pain and cried as a result of RP2's action. Witness testimony and documentation revealed RP2 had prior allegations of rough handling and requests by residents not to provide care needs. The facility did not produce a care plan upon request. The facility failed to provide a safe environment resulting in physical harm to Resident #1 by RP2. The failures are violations of resident rights, are considered neglect of care resulting in physical abuse. RP2 was also found responsible for physical abuse.",2,0,Substantiated,Substantiated,Physical Abuse +NW132572,70M053,ALF,12/20/2012,"Resident #1's belongings were given away to facility staff after Resident #1's spouse passed away and moved from the independent cottages to the licensed facility. Resident #1 began to exhibit intrusive and wandering behaviors showing clear distress of observing her/his belongings in parts of the facility. The facility responded by sending the resident out of the facility to a center that addresses behaviors. The facility failed to appropriately address Resident #1's behaviors and failed to use the resident's assets for her/his benefit. The failures are a violation of resident rights, are considered neglect of care and financial exploitation and constitute abuse.",3,300,,,Financial abuse +NW132941,70M053,ALF,2/1/2013,"Resident #1 was care planned for total assist and required one person transfers and toileting assistance. On multiple occasions, Resident #1's call light was not answered in a timely manner. Resident #1 was not treated with dignity and respect and peri-care was not properly conducted on occasion. The facility failed to answer call lights in a timely manner, failed to follow the care plan and failed to treat Resident #1 with dignity and respect. The failures are violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +NW135502,70M053,ALF,12/8/2013,"Resident #1 was identified as a fall risk and total assist with transfers. The service plan directed staff to make safety checks at night. On or about December 8, 2013, Resident #1 was found on the floor and transported to the hospital for treatment. Hospital records and witness testimony revealed Resident #1 had been on the floor for several hours. Review of the safety check logs showed no staff signatures. The facility failed to ensure the service plan was followed resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NW152969,70M053,ALF,9/27/2015,Resident #2 slapped and yelled at Resident #1 after Resident #1 attempted to take sugar and a coffee cup off of a table. Investigative details revealed a prior similar incident involving the two residents. The facility failed to address Resident #2's behavior resulting in an altercation with Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +NW148926,70M053,ALF,9/14/2014,"Resident #1 was admitted to the facility with a diagnosis of dementia. Three days later, Resident #1 was found injured, wandering outside in the early monring hours and was transferred the hospital for an evaluation. The facility failed to ensure a safe enviornment resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NW148928,70M053,ALF,10/2/2014,"Resident #1 was admitted to the facility with a diagnosis of dementia. Resident #1 had successfully eloped from the facility soon after being admitted. The facility failed to ensure a safe environment resulting in injury. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,, +NW152104,70M053,ALF,4/2/2015,"The facility failed to update Resident #1's care plan after the resident experienced a significant change of condition to address her/his falls. The resident continued to decline significantly over the next several weeks. The facility also failed to ensure the resident was safe after Resident #1 was left at the hospital with her/his spouse. Neither resident had the ability to appropriately communicate with hospital staff. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NW152105,70M053,ALF,4/24/2015,"The facility failed to update the care plan to address Resident #1's increased need including monitoring every two hours. The failure resulted in inadequate hygiene when Resident #1 was discovered covered in fecal matter by outside providers several hours after initial documentation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NW152114,70M053,ALF,4/30/2015,Resident #1 has a condition related to memory loss and identified as unsafe to leave the facility unassisted. Resident #1 left the facility at 3:00 am unnoticed and was returned to the facility by a good samaritan. The facility failed to appropriately monitor Resident #1 as care planned resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF117720,70M054,ALF,8/1/2011,Resident #1 and Resident #2 discovered money missing from their wallets from their respective rooms. An unknown individual is responsible for the theft of money.,2,0,Not Substantiated,Substantiated,Financial abuse +KF104073,70M054,ALF,4/19/2010,Resident #1 and Resident #2 did not receive the personal care they were paying for and their care plans were not being followed.,2,0,,,Neglect +KF120940,70M054,ALF,8/26/2012,"Resident #1 eloped from the facility on three separate occasions from August 16 to August 26, 2012. No injuries were sustained. The facility failed to assure Resident #1 was safe. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF121088,70M054,ALF,8/8/2012,"Resident #1 moved into the facility with the help of Reported Perpetrator 2 (RP2). He/she was not informed regarding all fees associated with the move in. Resident #1 did not sign any move in documents or authorizations. After he/she moved back home after seventeen days at the facility it was discovered that $8,000 had been automatically drafted from his/her bank account without Resident #1_x001A_s knowledge. The facility failed to protect Resident #1 from financial exploitation. RP2 was also found responsible for financial exploitation. The failure is a violation of resident rights and constitutes financial exploitation.",3,300,Substantiated,Substantiated,Financial abuse +KF121294,70M054,ALF,10/9/2012,"Resident #1 was assessed by the facility and determined that he/she required a walker for ambulation. He/she was designated a high fall risk and had increased confusion and issues with memory loss. Resident #1 fell and sustained a fractured left femur. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF121586,70M054,ALF,11/11/2012,"Resident #1 went to the restroom unattended during the night of 11/11/12 and fell sustaining a hip fracture. The facility failed to adequately update Resident #1_x001A_s service plan to address fall interventions. The facility also failed to follow Resident #1_x001A_s service plan relating to medication administration. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +KF120595,70M054,ALF,7/18/2012,"Resident #1 pulled their call cord in the early morning hours to request help with transferring to the bathroom. Reported Perpetrator 2 (RP2) told Resident #1 he/she was not able to transfer due to back issues. Another caregiver was on duty but was not contacted by RP2 for assistance. As a result, Resident #1 soiled his/her briefs and sheets. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF133011,70M054,ALF,4/22/2013,"Resident #1 had a rash that was noted by staff. The RN did not note any treatment in his/her service plan until a month later after the rash had spread and worsened. Resident #2 needed a two person assist. His/her service plan did not reflect this for over a month. The facility failed to provide needed services to the residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. + + + +This incident warrants a civil penalty; however, due to the fact that the facility had a change in the management company a civil penalty will not be issued.",3,0,,,Neglect +KF135441,70M054,ALF,12/13/2013,Resident #1 and Resident #2 did not receive the assistance that they needed from Reported Perpetrator 2 (RP2). The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF145568,70M054,ALF,1/3/2014,Resident #1 reported missing $175.00 from his/her room. An unknown individual was determined to be responsible for the loss of Resident #1's money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +KF146574,70M054,ALF,4/2/2014,Resident #1 reported $50 missing from his/her wallet. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +KF145980,70M054,ALF,2/3/2014,Resident #1's wallet was left in his/her pants and was taken to the laundry. When Resident #1 got the wallet back $32.00 was missing. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +KF146265,70M054,ALF,3/5/2014,It was reported that Resident #1 was missing ten $10.00 bills from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,350,Not Substantiated,Substantiated,Financial abuse +KF146242,70M054,ALF,3/3/2014,Resident #1's reported approximately $180 cash missing from his/her satchel. Three days later he/she reported another $40 missing. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +KF146652,70M054,ALF,4/7/2014,Resident #1 reported $400 missing from his/her room. Reported Perpetrator 2 (RP2) admitted taking the money. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +KF149192,70M054,ALF,11/9/2014,"The facility failed to adequately care plan related to Resident #1's falls. Resident #1 experienced several repeated falls resulting in bruising and skin tears. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules",2,,,,Neglect +GB118527B,70M055,ALF,11/8/2011,"Resident #1 was being given the wrong dosage of medication after h/h physician had made a change. Resident #2 attempted to leave the building on several occasions and was found just outside the door on one of those occasions with a lump on the left side of his/her head and bruises. Resident #4 eloped from the building undetected due to the door alarm not working. Resident #4 was found by the police in a ditch. Resident #4 was transported to the hospital; he/she had a fractured nose and required 5 stitches to their lip. The facility failed to provide a safe environment for residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +GB129239,70M055,ALF,2/3/2012,"Resident #1 pulled his/her call light for assistance at 4:00 am. Reported Perpetrator 2 (RP2) indicated he/she checked on him/her and did not reset Resident #1_x001A_s call light. Resident #1 was found deceased in his/her room at 6:00 a.m.. Between 4:00 a.m. and 6:00 a.m., Resident #1_x001A_s call light continued flashing and Resident #1 was not able to re-pull the cord to re-alert staff for assistance if needed. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Neglect +GB132409,70M055,ALF,2/5/2013,Resident #1 is bed bound and not able to communicate. His/her door was locked to protect Resident #1 from getting the flu. Resident #1 was not able to get up and unlock the door on his/her own if needed. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,,, +GB146938,70M055,ALF,4/30/2014,It was reported that Resident #1's wallet was missing from his/her room. It was found that Resident #1's credit card was being fraudulently used. Reported Perpetrator 2 (RP2) was identified as the person using the card in a store video. RP2 admitted taking the wallet and using the credit card. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES146718,70M056,ALF,4/10/2014,Resident #1 was left in his/her room for approximately four hours in a position where he/she could not move or summon help if needed. Resident #1 was not harmed and likely slept through it; yet exposed to potential for harm. The facility failed to monitor and provide a safe environment for Resident #1. The failures are a violation of resident rights and Oregon Administrative Rules.,2,,,, +WB150681,70M058,ALF,3/22/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +MV152371,70M058,ALF,8/5/2015,"Resident #1 had money and property go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +BH116303A,70M059,ALF,12/23/2010,A resident of the Facility was sent to the hospital and admitted due to a suspected narcotic overdose. The Facility was responsible for the administration of the resident's medications.,2,0,,,Neglect +BH116303B,70M059,ALF,12/23/2010,"A resident of the Facility presented to staff with elevated blood pressure and flu like symptoms that resulted in the resident experiencing vomiting. Facility staff was made aware of the resident_x001A_s condition and care giving staff took the resident's vitals, but no assessment by the Facility nurse took place. The resident_x001A_s family member contacted emergency services and the resident was transported to the hospital for treatment.",2,0,,, +BH120089,70M059,ALF,4/17/2012,"Narcotic medications were taken from medication bottles in the medication room, some replaced with other pills, and narcotics were missing belonging to Resident #1, Resident #2 and Resident #3. The Facility failed to have a safe medication administration system and failed to have an audit tracking system in place to prevent theft of narcotics. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +BH121092,70M059,ALF,9/12/2012,Resident #1 had eye surgery and eye drops were prescribed by his/her physician. Due to an error on the Medical Administration Record (MAR) the facility failed to administer the drops as prescribed by his/her physician. Resident #1 missed doses of his/her eye drops. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH121090,70M059,ALF,8/31/2012,Resident #1 requested help with his/her baked potato. He/she requested to have the potato cut out of the skin because it was too hard. Resident #1 has a medical condition that makes it difficult for him/her to use his/her hands. The request was denied. The facility failed to assist Resident #1 with eating and treat him/her with dignity and respect. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH132209,70M059,ALF,1/8/2013,The facility failed to administer Resident #1_x001A_s medications according to physician_x001A_s orders. Resident #1 did not suffer any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH149694,70M059,ALF,11/8/2014,"On November 18, 2014, Resident #1 expressed that he/she was having shortness of breath on and off all day. Resident #1 awoke on November 19, 2014, experiencing severe breathing difficulties. Resident #1 was not properly assessed or sent out to the hospital. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to properly assess Resident #1 for a change of condition and obtain timely medical treatment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,Substantiated,Substantiated,Neglect +BH159766,70M059,ALF,12/26/2014,Resident #1 has a diagnosis of memory loss. He/she is allowed to come and go from the facility. The facility has received calls from the community regarding Resident #1_x001A_s risky behaviors. Most recently he/she was at the bank and was unable to provide any information due to confusion. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH146212A,70M059,ALF,2/25/2014,Resident #1 was asked if he/she wanted to shower. Resident #1 agreed to shower and refused when he/she was half showered. Staff competed the task. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH146212B,70M059,ALF,2/25/2014,Resident #1 was prescribed a medication to be administered three times daily. Resident #1 missed doses of the medication due to it not being transcribed in the Medication Administration Record. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH164430,70M059,ALF,1/21/2016,"Resident #1, Resident #2 and Resident #3 were found wet and soiled the morning of January 21, 2016. Care plans for all three residents stated they were to have brief changes during the night shift. The facility failed to follow care plans for Resident #1, Resident #2, Resident #3 and appropriately train staff. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +SV117699,70M060,ALF,8/12/2011,The facility failed to provide a safe medication administration system resulting in the potential for harm to residents. The failure is a violation of OARs.,2,0,,, +MV118062,70M060,ALF,9/15/2011,"Resident #1 was asked and indicated she/he did not request narcotic medications as shown on her/his MAR. RP2 signed out for the medications, but denied taking them and refused to take a drug test. The facility failed to provide a safe environment resulting in loss of medications. RP2 was apportioned abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +MV121214,70M060,ALF,9/26/2012,"Resident #1 discovered $140.00 cash missing from her/his room. RP2 was suspected, however it was unable to be concluded who was repsonsible for the theft of money. The facility failed to ensure a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +MV121333,70M060,ALF,9/30/2012,Resident #1 required regularly scheduled blood glucose readings. Observation of the blood glucose reading on the glucometer did not match the paper record maintained by RP2. It was concluded that RP2 improperly documented blood glucose readings. The facility failed to ensure physician treatment order was conducted resulting in the potential for harm to Resident #1 and Resident #2. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV121165,70M060,ALF,9/20/2012,It was reported that Reported Perpetrator 2 (RP2) purposely gave Resident #1 a medication that prevented him/her from drinking alcohol and then confiscated Resident #1's purchased alcohol upon Resident #1 returning to the facility. RP2 stated Resident #1 knew he/she was taking a certain medication that could have potential side effects with alcohol. RP2 failed to assure Resident's Rights by taking Resident #'1s personal property against his/her will. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV148048,70M060,ALF,8/2/2014,"Resident #1 was care planned for two person transfers. On or about the evening of August 2, 2014, RP2 discovered Resident #1 injured on the floor next to her/his bed. RP2 was the only caregiver present and waited until another staff member came on shift prior to contacting 911. The facility failed to ensure two qualified caregivers were present, failed to ensure appropriate staff training and failed to provide a safe environment resulting in unreasonable discomfort to Resident #1. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV149428A,70M060,ALF,12/1/2014,"The facility failed to adequately care plan after Resident #1's experienced increased behaviors and difficulty in redirection. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MV159782,70M060,ALF,1/5/2015,"Resident #1 had a history of refusing care and was care planned to address it. On or about January 4, 2015, RP2 and RP3 were observed physically forcing care despite continued refusal from Resident #1. The facility failed to ensure Resident #1's care plan was followed as directed and failed to document an investigation which is a violation of Oregon Administrative Rules. RP2 and RP3 were found responsible for physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +MV150867,70M060,ALF,4/9/2015,"On or about April 9, 2015, Resident #1's cane was taken away after observation showed she/he was using it as a potential weapon. There was no documentation related to the incident or care plan regarding the removal of the cane. The facility failed to care plan and maintain documentation related to Resident #1's physical behavior history. The failures are a violation of Oregon Administrative Rules.",2,,,, +MV153616,70M060,ALF,10/23/2015,"Resident #1 was administered a medication that the facility was aware the resident had an allergy to. The facility failed to appropriately monitor, consult with the physician or timely seek medical attention resulting in the development of a rash. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BA117340,70M061,ALF,5/30/2011,"A resident of the Facility who had a history of pretending to be suffering from medical conditions was found to be laying on the floor in his/her room, blocking the egress of staff from entering the residents room. Staff came by multiple times to check on the resident but was not able to access the resident's room. Eventually the staff climbed through the window.",1,0,,, +BA117931,70M061,ALF,7/26/2011,Resident #1 has specific behaviors which care plan directs staff on how to deal with. RP2 failed to follow the care plan and used verbal inappropriate behavior. The facility failed to assure resident rights. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +BA118179,70M061,ALF,9/14/2011,"RP2 was called away from medication administration duty resulting in Resident #1 not receiving her/his medication as ordered. The facility failed to proivde a safe medication administration system resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +OT129943,70M061,ALF,4/26/2012,"Resident #1 is incontinent of both bladder and bowel. He/she is unable to inform staff of bladder/bowel needs. He/she goes for hours without changing of under garments. Resident #1 was noted to have a spot on his/her tailbone thought to be the start of a pressure sore. There was no documentation indicating follow-up and out-come of suspected pressure sore. Also, Resident #1_x001A_s room presents as unclean with stains to the carpet and unclean counters/surfaces. The room also smells of urine at times. The facility failed to assure resident rights and protections and follow care plan for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO12128,70M061,ALF,11/15/2012,"The facility failed to evaluate, develop appropriate interventions, monitor and provide an RN assessment and ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing. Resident #2 had wounds that worsened. Resident #3 and #7 lost a severe amount of weight. Resident #8 endangered him/her and other residents due to ""helping"" by trying to provide care, including toileting, resulting in Resident #1 being injured. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,1500,,,Neglect +BA120926,70M061,ALF,7/12/2012,"The facility failed to ensure Resident #1 was evaluated and monitored according to his/her change of condition; and failed to ensure his/her service plan was reflective of his/her needs. Resident #1 was admitted to the hospital on July 10, 2013. Resident #1 lost a significant amount of weight and had decubitus ulcers. The failures are a violation of resident rights, are considered neglect of care and constitute abuse",3,300,,,Neglect +BA121620,70M061,ALF,6/6/2012,Resident #1 was not administered his/her medications according to his/her physician_x001A_s orders. Pertinent information regarding Resident #1_x001A_s medication schedule was neither notated nor properly briefed to pm shift. The paper Medication Administration Record was either misplaced and/or not available to pm shift. Resident #1 experienced lethargy and generally not feeling well. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA121610,70M061,ALF,9/3/2012,"It was reported that the facility failed to provide a safe environment to ensure the health, safety and well being of Resident #1. The facility failed to administer medicated powder as prescribed for Resident #1. The facility also failed to assure resident rights. The failures are a violation of Oregon Administrative Rules.",2,0,,, +BA132107,70M061,ALF,12/24/2012,Resident #1 took medications belonging to another resident. There were no adverse side effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA132464,70M061,ALF,1/28/2013,Resident #1 did not receive six scheduled medications resulting in withdrawals and pain. The medications had been signed off as given and had not been administered to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA132549,70M061,ALF,2/19/2013,It was reported that Resident #1 and Reported Perpetrator 2 (RP2) argued regarding an issue that did not relate to Resident #1's care or wellbeing. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA134885,70M061,ALF,9/20/2013,"The facility administered medications at times prescribed by Resident #1's physician however, medication was administered at the wrong dosage level. Resident #1 became unresponsive and was transported to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BA134886A,70M061,ALF,10/7/2013,Resident #1 is prescribed a pain patch to be administered every three days. Resident #1 was administered a pain patch on 10/4/13 and was scheduled to have another on 10/7/13. The Medication Administration Record showed the pain patch was administered but was not. Resident #1 suffered discomfort from not receiving the pain patch as scheduled. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA134886B,70M061,ALF,10/7/2013,Resident #1's nitroglycerine patch was not removed for the night as ordered. Resident #1 had no negative outcome. A check box has been added to the Medication Administration Record for initialing when the patch is removed. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA145815,70M061,ALF,12/27/2013,"Resident #1's care plan stated he/she required assistance to and from activities, he/she was an elopement risk, and was not to leave the facility alone. Resident #1 was sent to a doctor's appointment alone. While waiting for the bus to pick him/her up the wheelchair went off the curb and tipped over. Resident #1 was taken to the hospital and had sustained compressed fractures in his/her back. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BA145705B,70M061,ALF,12/23/2013,"During medication administration Resident #1 was given one of his/her glasses with water. Resident #1 had bleach in the cup prior to this and there was still residue in the glass. Resident #1 experienced no negative effects. The facility will now only use paper cups from the medication cart, not personal cups. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA146519A,70M061,ALF,12/26/2013,Resident #1 takes narcotic pain medication every four hours. On multiple occasions he/she has been administered pain medications greater than 30 minutes before or after the prescribed time frame. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon administrative Rules.,2,,,, +BA146519B,70M061,ALF,12/26/2013,"Resident #1 was prescribed a pain patch to be changed every 72 hours. + +On 12/26/13 the Medication Administration Record (MAR) documentation indicated that it was changed. It was discovered on 12/30/13 that it had not been changed. Resident #1 experienced discomfort and pain. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA146576,70M061,ALF,2/3/2014,Resident #1 has a prescription order for 100mcg pain patch every three days. Reported Perpetrator 2 (RP2) administered two pain patches for a total of 150mcg to RV. RP2 failed to administer the correct pain patch dose to Resident #1. This failure is considered neglect of care and constitutes abuse. The facility failed to ensure an accurate medication administration system. This failure is a violation of Oregon Administrative Rule.,2,,Not Substantiated,Substantiated,Neglect +BA146809,70M061,ALF,1/10/2014,"Resident #1, Resident #2 and Resident #3 were not administered their medications according to physician's orders. None of the residents had a negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +BA147036,70M061,ALF,2/3/2013,"Resident #1 requested cough syrup but Reported Perpetrator 2 (RP2) was unable to give the cough syrup due to a required waiting period between pain management medications and the cough syrup. RP2 gave Resident #1 a cough drop. There was no physician's order for the cough drop. The facility failed to provide a safe medication administration system. + +The failure is a violation of Oregon Administrative Rules.",2,,,, +BA132145,70M061,ALF,12/1/2012,Reported Perpetrator 2 (RP2) left his/her shift without permission or completing his/her assigned duties due to being ill. Resident's incontinent briefs were not changed and none of the other tasks listed on the care plans were completed. The facility failed to assure that resident care plans were followed. The failures are a violation of Oregon Administrative Rules.,2,,,, +BA147689,70M061,ALF,6/4/2014,"The facility failed to administer Resident #1's pain medications as perscribed. Resident #1 was in pain for several hours due to missing the medication. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +BA148130A,70M061,ALF,6/9/2014,"The facility failed to assess and intervene when Resident #1 experienced a change of condition related to blood pressure overmedication. Resident #1 continued to exhibit symptoms of overmedication was sent to a hospital for treatment. This failure is considered neglect of care, constitutes abuse, and violates Oregon Administrative Rules.",3,,,,Neglect +BA148390,70M061,ALF,7/5/2014,"The facility failed to provide Resident #1 their blood pressure medication on two separate occasions, which exposed Resident #1 to potential harm. This violation is considered neglect of care, constitues abuse, and is a violation of Oregon Administrative Rules.",2,,,, +BA121522,70M061,ALF,7/25/2012,Facility staff gave Resident #1 his/her medications and left his/her room. The facility staff failed to observe Resident #1 take his/her medications. This failure is a violation of Oregon Administrative Rules.,2,,,, +BA148131B,70M061,ALF,6/7/2014,"The facility failed to order Resident #1 incontinence supplies. Resident #1 was found soaked in his/her own urine by family members on Father's Day. Another family member found Resident #1 naked from the waste down the next day. This failure is considered neglect of care, which constitutes abuse, and is a violation or Oregon Administrative Rules.",2,,,,Neglect +BA148743,70M061,ALF,7/26/2014,The facility failed to respond when Resident #1's wander guard alarm went off. Resident #1 was able to wander outside of the facility and no facility staff responded to his/her wander guard alarm. This failure is a violation of Oregon Administrative Rules.,2,,,, +BA149658A,70M061,ALF,10/2/2014,The facility failed to administer Resident #1's medication in a timely manner. Resident #1 received her medication a few hours late on two separate occasions. This failure is a violation of Oregon Administration Rules.,2,,,, +BA149658B,70M061,ALF,10/2/2014,The facility failed to adequately follow Resident #1's care plan to attempt to calm Resident #1 when he/she gets upset. A facility staff member was observed arguing with Resident #1 rather than walking away and coming back when Resident #1 calmed down. This failure is a violation of Oregon Administrative Rules.,2,,,, +BA159976,70M061,ALF,9/30/2014,"The facility and Reported Perpetrator #2 (RP2) failed to adequately follow Resident #1 and Resident #2's care plans. Both residents did not receive incontinent assistance as specified in their care plans, and were left in wet incontinence products and bedding. This failures is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,Substantiated,Substantiated,Neglect +BA159965A,70M061,ALF,9/30/2014,Reported Perpetrator #2 (RP2) grabbed Resident #1's hand and shook it trying to get Resident #1 to drop a sandwich. Resident #1 sustained bruising to his/her hands as a result. RP2 is responsible for physical abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BA159965B,70M061,ALF,9/30/2014,The facility failed to ensure Resident #1 was treated with dignity and respect. Reported Perpetrator #2 yelled at Resident #1 to drop a sandwich. This failure is a violation of Oregon Administrative Rules.,2,,,, +BA152427,70M061,ALF,7/31/2015,The facility failed to provide Resident #1 medication as ordered. This failure is a violation of Oregon Administrative Rules.,2,,,, +CO15254,70M061,ALF,9/29/2015,,4,,,, +BC147030,70M063,ALF,4/7/2014,The facility failed to ensure a safe medication administration system and failed to have an accurate medication administration record for Resident #1's medications.,2,,,, +AS117146,70M064,ALF,6/3/2011,The facility failed to monitor Resident #1's medication administration as care planned resulting in the potential for harm. Two blood pressure pills were found on the floor in the resident's room. The failures are violation of OARs.,2,0,,, +CO14060,70M064,ALF,2/27/2014,"The facility failed to ensure physician orders were followed for Resident #4. Resident #4_x001A_s anti-anxiety medication was not available resulting in being transported to the hospital for treatment of pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AS148403,70M064,ALF,8/29/2014,"The facility failed to administer Resident #1's medication for three days resulting in the potential for harm. The failure is a violation Oregon Administrative Rules. License Condition # ALFCP14-005 was issued effective September 18, 2014 based on survey citation including but not limited to an unsafe medication administration system.",2,,,, +AS148406,70M064,ALF,8/6/2014,"Resident #1 was not provided with her/his prescribed narcotic medication when she/he moved to another facility resulting in unreasonable discomfort for several days. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. License Condition # ALFCP14-005 was issued effective September 18, 2014 based on survey citation including but not limited to an unsafe medication administration system.",3,,,,Neglect +AS148384,70M064,ALF,8/19/2014,Complainant reported concerns related to Resident #1's care needs. There was also a concern regarding Resident #2's sore. Resident #1 required lotion to be applied daily. Witness testimony and facility documentation revealed that lotion was not being applied as care planned. The failure is a violation of Oregon Administrative Rules.,2,,,, +AS149344,70M064,ALF,11/24/2014,"Resident #1 reported two rings missing from a drawer in her/his room. Proper authorities were notified and an investigation was initiated. Witness statements confirmed that the rings existed, however no suspects were able to be identified. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +CO15197,70M065,ALF,9/22/2015,"The facility failed to ensure interventions were monitored for effectiveness for Resident #1 who experienced unrelieved pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS117335,70M066,ALF,6/29/2011,"The facility failed to have a system in place to prevent theft or misuse of medications resulting in the loss of narcotic medications. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +MS117488,70M066,ALF,7/19/2011,"Resident #1 reported up to 40 narcotic pain pills missing from her/his room. RP2 was suspected, but there is not enough evidence to determine who took Resident #1's narcotics. The facility failed to provide a safe environment resulting in the loss of a residents' medication. An unknown person was apportioned abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +MS118029,70M066,ALF,9/5/2011,"Resident #1's PRN medications went missing from the medication room. The facility failed to provide a safe medication administration system resulting in the loss of Resident #1's medication. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,250,,,Financial abuse +MS121700,70M066,ALF,11/25/2012,"Resident #1 had a history of falls, known inability to utilize the call system and poor safety awareness. On November 25, 2012, Resident #1 experienced two falls resulting in transportation to the hospital for treatment of a fractured clavicle and stitches for a head wound. The facility failed to adequately care plan related to falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS146609,70M066,ALF,3/27/2014,RP2 administered Resident #1 another resident's medication resulting in drowsiness. Witness testimony and facility documentation revealed the facility appropriately responded to the situation and monitored the resident with no negative outcome. The facility failed to ensure a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS150715,70M066,ALF,3/26/2015,"Resident #1 had a diagnosis related to memory loss and documented as a fall risk. Between January and March 2015, Resident #1 was found on the floor six times, two resulted in injury. There were no documented changes to the resident's care plan to address the last five incidents. The facility failed to adequately care plan for falls resulting in transportation to the hospital for treatment of a head wound. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS153284,70M066,ALF,10/26/2015,"The facility failed to effectively communicate necessary information with Resident #1's physician regarding her/his suture removal. Resident #1's sutures were not removed in a timely manner and an infection was observed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NB118304,70M067,ALF,10/18/2011,"RP2 borrowed Resident #1's keys that included a key that accessed Resident #1's lockbox. Resident #1 later discovered missing jewelry valued at $6,900 from the lockbox. RP2 had access to Resident #1's room with her/his own set of keys. Based on investigative findings, RP2 was apportioned abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +RB128829B,70M067,ALF,12/30/2011,"Reported Perpetrator 2 (RP2) mismanaged, co-mingled, and lacked adequate tracking of residents PIF accounts. The facility and RP2 failed to maintain an adequate financial management and accounting system for residents_x001A_ accounts. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",3,300,Substantiated,Substantiated,Financial abuse +NB118595,70M067,ALF,11/28/2011,"Resident #1, Resident #2 and Resident #3 reported theft of jewelry and Resident #4 reported theft of approximately 25-30 prescription pain medications. Resident #1, Resident #2 and Resident #4 did not have keys to their locking security drawer. An unknown individual is responsible for the theft of jewelry and medications. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +NB129070,70M067,ALF,1/25/2012,Resident #1's had a history of verbal aggression behaviors and his/her care plan instructed staff on interventions. Staff argued with him/her making the situations worse; and did not follow his/her care plan. The facility failed to ensure Resident #1's care plan was followed. The failure is a violation of Oregon Administrative Rules.,1,0,,, +NB128967,70M067,ALF,1/17/2012,"Resident #1 requested his/her watch be placed in the facility safe for safekeeping, which Reported Perpetrator 2 (RP2) did. The watch was discovered missing. The safe did not operate correctly and had been left unlocked; and there was no documentation regarding the watch being placed in the safe. The facility and RP2 are responsible for financial abuse and both failed to provide a safe and secure environment resulting in the loss of Resident #1's watch with sentimental value. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,300,Substantiated,Substantiated,Financial abuse +NB129970,70M067,ALF,5/2/2012,"Resident #1 was prescribed a medication patch per day, to be removed after 12 hours and a new patch applied. On 5/3/12, two patches were discovered on his/her back dated 4/30/12 and 5/2/12. Resident #1 fainted secondary to the medication patch overdose. The facility failed to maintain a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +NB120411,70M067,ALF,7/2/2012,On 7/2/12 Resident #1 noticed his/her wallet containing approximately $200 was missing. Facility staff searched the facility and was unable to locate the wallet or missing money. An unknown individual is responsible for the theft of money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +NB129194A,70M067,ALF,12/27/2011,"Reported Perpetrator 2 (RP2) mismanaged, co-mingled, and lacked adequate tracking of residents PIF accounts. The facility and RP2 failed to maintain an adequate financial management and accounting system for residents_x001A_ accounts. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. The abuse is apportioned to the facility and RP2. + + + +The Notification of Findings was completed at a later date (A civil penalty was not issued) due to the extended period of time between the incident date and processing by the Department.",3,0,Substantiated,Substantiated,Financial abuse +NB129194B,70M067,ALF,12/27/2011,"Reported Perpetrator 2 (RP2) mismanaged, co-mingled, and lacked adequate tracking of residents PIF accounts. The facility and RP2 failed to maintain an adequate financial management and accounting system for residents_x001A_ accounts. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. The abuse is apportioned to the facility and RP2. + + + +The Notification of Findings was completed at a later date (A civil penalty was not issued) due to the extended period of time between the incident date and processing by the Department.",4,0,Substantiated,Substantiated,Financial abuse +NB132603,70M067,ALF,3/10/2013,"Reported Perpetrator 2 (RP2) failed to follow Resident #1's care plan resulting in a fall causing a torn ligament. RP2 is found responsible for abuse, by neglect of care. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Neglect +NB132634,70M067,ALF,2/27/2013,The facility failed to provide a safe medication administration system and failed to provide appropriate staff oversight. The failure resulted in several occasions where Reported Perpetrator 2 (RP2) did not administer medications to Resident #1 and Resident #2 as ordered. The failures are a violation of Oregon Administrative Rules.,2,0,,, +NB132736,70M067,ALF,3/16/2013,Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) failed to administer ordered medication to Resident #1 and Resident #2. Neither resident experienced a negative outcome. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +NB133569,70M067,ALF,6/21/2013,"Residents #1, 2 & 3 missed medications due to medication errors. Reported Perpetrator 2 (RP2) failed to report the errors to the facility or write Incident Reports regarding the errors. RP2 failed to assess the residents when it was discovered they'd missed medications. Resident #2 suffered some negative side effects after resuming the correct dosage of the missed medication. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 is responsible for neglect of care, which constitutes abuse.",2,300,Substantiated,Substantiated,Neglect +NB134547,70M067,ALF,9/9/2013,"The Facility failed to ensure staff reported Resident #_x001A_1_x001A_s change of condition of his/her wound. Resident #1 was transported and admitted to the hospital due to his/her wound. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NB146404,70M067,ALF,3/18/2014,Resident #1 was given 50 mg of medication instead of 25 mg. The prescription had recently changed. Resident #1 had no negative outcome from the dosage mistake. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB146484,70M067,ALF,3/24/2014,Resident #1 reported the contents of a package containing a $600 ring missing. The package was placed in a common dining room. The contents of the package disappeared before Resident #1 was able to retrieve it. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +NB146368,70M067,ALF,3/14/2014,"Reported Perpetrator 2 (RP2) entered into an agreement with Resident #1 to purchase his/her camp trailer for $8,000. RP2 obtained possession of the camp trailer in January 2014. RP2 failed to pay Resident #1 any money as agreed. Resident #1 demanded RP2 return the camp trailer no later than April 2014. RP2 failed to return the camp trailer or pay Resident #1 for the camp trailer. RP2 was determined to be responsible for financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",4,,Not Substantiated,Substantiated,Financial abuse +NB147366A,70M067,ALF,6/12/2014,"Resident #1 was not administered his/her pain medication per the physician's order. Resident #1 experienced pain as a result. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +NB147366C,70M067,ALF,6/12/2014,Resident #3 had a wound that required daily wound care. Reported Perpetrator 2 (RP2) provided wound care to Resident #3. Resident #3 refused to let RP2 provide further wound care due to RP2 being too rough. The facility failed to provide medical treatment as ordered regarding wound care. The facility also failed to provide appropriate training to staff regarding medical treatment orders. The failures are a violation of Oregon Administrative Rules.,2,,,, +NB147366B,70M067,ALF,6/12/2014,Resident #2 requested a PRN pain medication and it was not administered to him/her upon request. Reported Perpetrator 2 (RP2) failed to check the MAR to make sure the administration times were correct. The facility failed to administer Resident #2's PRN medication as ordered and provide appropriate training to staff. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB148483,70M067,ALF,9/11/2014,Resident #1 was administered one extra tablet of pain medication. There had been a recent change from the pharmacy in the amount of milligrams per pill. The change involved Resident #1 receiving one pill instead of two. Resident #1 experienced no adverse effects. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB148029,70M067,ALF,8/4/2014,Resident #1 was to be given a narcotic medication twice per day. It was discovered that the narcotic count was off by one pill. Reported Perpetrator 2 (RP2) denied knowledge of what happened to the missing narcotic pill. The facility failed to provide a system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB149083,70M067,ALF,10/27/2014,Resident #1 had a prescribed narcotic medication that he/she did not take. The medication expired and was put into the section of the med cart for medications to be destroyed. One tablet came up missing during the medication count. It was not clear where it went or even when it actually first went missing. The facility failed to provide a medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB159927,70M067,ALF,1/14/2015,Resident #2 was administered Resident #1's medication in error. Both residents take the same medication just a different dose. Resident #2 did not experience any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +NB152152,70M067,ALF,7/13/2015,"Reported Perpetrator #2 (RP2) failed to document Resident #1 required alert charting and monitoring of a wound on Resident #1's inner ankle. The wound worsened and Resident #1 required antibiotic treatment. RP2 is responsible for neglect of care. The facility failed to provide a safe environment for Resident #1, which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +NB152707,70M067,ALF,9/3/2015,"Resident #1's call pendant was not working so he/she had given it to a staff member. Resident #1 did not receive a replacement. Resident #1 fell that evening in his/her room. The care plan stated that he/she does call for assistance. Resident #1 was transported to the hospital where he/she was diagnosed with a fracture of the lower leg. The facility failed to assure Resident #1 was safe. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +NW120669,70M068,ALF,5/21/2012,"Resident #1 pulled her/his call light for assistance to bed approximately 2:00 AM on or about May 23, 2012. RP2 failed to answer the call light in a timely manner and waited until another staff person came off of break to find Resident #1 asleep. The following day, Resident #1 was discovered with a laceration that she/he incured while self transferring to bed the previous night and required transporation to the hospital for treatment. The facility failed to ensure Resident #1's service plan was followed resulting in harm and potential for serious harm. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect and is considered abuse.",3,0,Not Substantiated,Substantiated,Neglect +CO12117,70M068,ALF,9/20/2012,"The facility failed to ensure consistent and timely evaluation, assessment, monitoring and treatment of open areas resulting in skin breakdown for Resident #6 on two occasions. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NW134487,70M068,ALF,6/29/2013,"Resident #1's Service Plan required a gait belt while ambulating with him/her. Reported Perpetrator 2 did not use a gait belt while assisting Resident #1 when he/she fell, was transported to the hospital and diagnosed with a dislocated a shoulder. The facility failed to provide a safe environment, which is a violation of resident rights. Reported Perpetrator 2 is responsible for failing to follow the Service Plan, which is considered neglect of care and constitutes abuse.",3,,Not Substantiated,Substantiated,Neglect +NW148938,70M068,ALF,9/21/2014,An investigation was conducted after a concern regarding rough treatment by RP2. Investigative findings determined RP2 roughly moved footrests causing a skin tear to Resident #1's leg. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +NW152079,70M068,ALF,4/16/2015,"RV1 ambulated with a wheelchair and required assistance with showering, dressing and transfers. RV1 was dropped off at a community pool by facility staff alone. Lifeguards and community members assisted RV1 in the pool and dressing in the locker room. The facility's failure to provide a safe environment and failure to follow RV1's service plan placed him/her at a high risk of harm and are violations of the Oregon Administrative Rules.",2,,,, +HB116435,70M070,ALF,2/27/2011,"Many residents of the Facility's first floor did not receive their medications on time, or at all during a shift in which an untrained staff member was left to perform medication administration by his/her self.",2,0,,, +HB116592,70M070,ALF,3/23/2011,"A resident of the Facility was given too much pain medication by a Facility staff member, Reported Perpetrator #2 (RP2) who did not read and/or follow the MAR closely enough. The resident described having a negative outcome as a result of the medication error.",2,0,,,Neglect +HB116734,70M070,ALF,4/11/2011,Narcotics were discovered missing while completing medication counts for multiple residents. Internal investigation was conducted and determined RP2's work schedule correlated with missing residents' medications. The facility failed to provide a safe environment resulting in the loss of resident's medications. Preponderance of evidence determined abuse is apportioned to RP2.,2,0,Not Substantiated,Substantiated,Financial abuse +HB117101,70M070,ALF,5/30/2011,"The Medication Administration Record (MAR) was incorrectly transcribed resulting in Resident #1 not receiving medication as ordered for almost a month. The facility failed to provide a safe medication administration system resulting in the potential for serious harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB117270,70M070,ALF,6/20/2011,The facility failed to provide a safe environment resulting in the elopement of Resident #1. Resident #1 was able to elope from the facility because the batteries went dead on her/his door alarm. The failure is a potential for harm and is a violation of OARs.,2,0,,, +HB117272,70M070,ALF,6/21/2011,Resident #1's Medication Administration Record was not updated after the physician changed the dosage on two supplements resulting in the resident receiving the wrong dosage for seven weeks.,2,300,,, +HB133465,70M070,ALF,6/7/2013,"On or about June 10, 2013, Resident #1 reported money missing from her/his wallet on two separate occasions totaling $20. The local office was notified and an internal investigation was conducted, however no suspect could be identified. The facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for the thefts, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB133572,70M070,ALF,6/19/2013,"It was reported that $40 went missing from Resident #1's locked drawer. Resident #1's key to the locked drawer was stored in an unlocked drawer. Resident #1 agreed to open a trust account to keep money safe. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was held responsible for the theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB133433,70M070,ALF,6/7/2013,"Resident #1 was on alert charting due to shortness of breath between January and March, 2013. His/her care plan stated Resident #1 used inhalers and nebulizer treatments. There were no service notes regarding Resident #1's condition between March 16 and June 15, 2013. In early April a family member noticed Resident #1 was non-responsive, not feeling well and told facility staff to call emergency personnel. Resident #1 was diagnosed with pneumonia and spent several days in the hospital. The facility failed to intervene when Resident #1's condition changed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB133723,70M070,ALF,7/7/2013,"Resident #1 reported over $80 in cash missing and Resident #2 reported her/his I-Pad missing from their respective rooms. There has been a recent increase in thefts at the facility. The facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,350,Not Substantiated,Substantiated,Financial abuse +HB133745B,70M070,ALF,7/10/2013,RP2 forgot to provide a medication to Resident #1. RP2 retrieved the medication after Resident #1 notified RP2 of the mistake. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB133745A,70M070,ALF,7/10/2013,"Resident #1 expressed left foot pain after a fall. The facility failed to appropriately refer to the RN for follow up or document Resident #1's change of condition in a timely manner resulting in ongoing pain. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,350,,,Neglect +HB133870,70M070,ALF,7/22/2013,Resident #1 fell and hit her/his head. RP2 responded to the call light several minutes later but failed to follow proper procedure. Resident #1's fall was not documented or appropriate staff notified. Facility staff responded after Resident #1 complained of pain and dizziness later that day. The failure is a violation of Oregon Administrative Rules and is a potential for harm.,2,,,, +HB134108,70M070,ALF,8/14/2013,Resident #1 has a physician's order to administer medication twice daily with breakfast and dinner. Blood pressure is to be checked prior to administration. The facility failed to consistently administer Resident #1 her/his medication as ordered and failed to document the time on the Medication Administration Record. The failure is a violation of Oregon Administrative Rules and is a potential for harm.,2,,,, +HB134018,70M070,ALF,8/3/2013,"Three residents reported missing multiple items. The facility failed to provide a safe environment and is a failure of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB133992,70M070,ALF,8/2/2013,"Resident #1 reported that on two occassions money went missing from room. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB134382,70M070,ALF,9/11/2013,"Resident #1 reported a medication card containing 20 narcotic pills missing from her/his locked drawer. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB134496,70M070,ALF,9/23/2013,"Resident #1 had a chronic medical condition that required daily treatment. On or about September 22, 2013 treatment was not completed. The facility failed to ensure medication was administered as ordered and is a violation of Oregon Administrative Rules.",2,,,, +HB134759,70M070,ALF,10/16/2013,"On or about October 15, 2013, medications were several hours late. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB135142,70M070,ALF,11/21/2013,"Resident #1 has a physician's order for continuous oxygen use and is care planned for facility monitoring and management. On two know occassions, Resident #1 ran out of oxygen. The facility failed to appropriately monitor and manage Resident#1's oxygen. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB135439,70M070,ALF,12/20/2013,"Resident #1 reported jewelry missing from a locked drawer in her/his room. The facility failed to provide a safe environment resulting in loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,300,Not Substantiated,Substantiated,Financial abuse +HB147074,70M070,ALF,5/15/2014,"Resident #1 reported missing a laptop. It was confirmed that a laptop was given to Resident #1. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +HB147238B,70M070,ALF,5/29/2014,"Resident #1 was given given a different medication other than the anxiety medication prescribed by his/her medical doctor. An investigation determined Reported Perpetrator #2 gave Resident #1 the wrong medication. Reported Perpetrator #2 was found responsible for neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules. The facility failed to insure Resident #1 received their medication as ordered. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +HB147122,70M070,ALF,5/17/2014,The facility failed to administer medication to Resident #1 and Resident #2 as ordered. Both Resident #1 and Resident #2 missed a dose of medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB148212,70M070,ALF,8/20/2014,Resident #1 was care planned for stand-by assistance while toileting. The facility failed to ensure Resident #1's care plan was followed leaving Resident #1 on the toilet by him/herself for up to 25 minutes. This failure is a violation of Oregon Administrative Rules.,,,,, +HB148244,70M070,ALF,8/22/2014,"The facility failed to follow Resident #1's care plan for a two person assist during transfers to the toilet and to his/her wheelchair. Resident #1 was commonly transferred with only a one person assist exposing him/her to potential harm. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +HB148395,70M070,ALF,9/4/2014,The facility failed to adequately label a bottle containing Resident #1's medication. Since it was not labeled Resident #1 went 3 days without medication due to facility staff not knowing the bottle was Resident #1's. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB149100,70M070,ALF,10/31/2014,"The facility failed to fill Resident #1's pain medication in timely manner. Resident #1 exhibited increased pain and withdrawal symptoms for the days she went without her pain medication as a result. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB149230B,70M070,ALF,11/14/2014,The facility failed to administer Resident #1's medication as prescribed resulting in Resident #1 missing a dose of medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB149668A,70M070,ALF,12/23/2014,The facility failed to monitor Resident #1's temperature as directed. Resident #1's temperature was recorded 5 times out of the 14 times required. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB149668B,70M070,ALF,12/23/2014,The facility failed to protect Resident #1 from inappropriate comments. Resident #1 was told he/she was rude. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB149668C,70M070,ALF,12/23/2014,The facility failed to administer a safe medication administration system. Resident #1 was given a different residents medication by mistake. Resident #1 recognized the mistake and did not take the other medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB149693,70M070,ALF,12/24/2014,The facility failed to adequately maintain a safe medication administration system. Multiple medications administered to Resident #1 were not reflected in the facility MAR timely. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB159781,70M070,ALF,1/5/2015,"The facility and Reported Perpetrator 2 (RP2) failed to seek timely medical attention for Resident #1. Resident #1 waited several hours for the facility and RP2 to call paramedics for transport to a hospital. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +HB150579,70M070,ALF,3/16/2015,"The facility failed to administer Resident #1_x001A_s pain medication in a timely manner. Resident #1 experienced increased pain for several hours due to the delay. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +HB150462,70M070,ALF,3/4/2015,The facility failed to administer Resident #1's medication for several days. There was no negative effect to the resident. This failure is a violation of Oregon Administrative Rules.,2,,,, +CO15105,70M070,ALF,6/1/2015,,3,0,,, +HB150694,70M070,ALF,3/25/2015,The facility failed to administer a safe medication administration system in relation to Resident #1 being given another Resident's medication in error. Resident #1 noticed the error and did not ingest the medication. This failure is a violation of Oregon Administrative Rules.,2,200,,, +HB150428,70M070,ALF,3/2/2015,"The facility failed to administer Resident #1 and Resident #2's medications in a timely manner. Resident #2 experienced increased pain and discomfort due to the delay. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +HB151281B,70M070,ALF,5/15/2015,Resident #1 felt humiliated and belittled during a conversation held with Reported Perpetrator #2 (RP2). The comments made by RP2 are considered verbal abuse and RP2 is responsible for making them. The facility failed to provide a safe environment for Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +HB151608B,70M070,ALF,6/17/2015,The facility failed to administer medication as ordered. Resident #1 had a prescription order for medication to be given at 2:00PM. The facility tried to give it to him/her at 12:00PM. This failure is a violation of Oregon Administrative Rules.,2,,,, +HB151809,70M070,ALF,7/6/2015,"The facility failed to answer Resident #1's call light in a timely manner. Resident #1 was left on the toilet for over 30 minutes and experienced pain and numbness in his/her legs. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +OR0001000500,70M070,ALF,9/8/2015,,1,,Not Substantiated,Substantiated, +HB153793,70M070,ALF,12/2/2015,The facility failed to assist Resident #1 with adjusting his/her microwave tray. This failure is a violation of Oregon Administrative Rules.,2,,,, +OR0001026001,70M070,ALF,11/5/2015,,1,,,Substantiated, +OR0001026002,70M070,ALF,11/5/2015,,1,,,Substantiated, +DL121705,70M071,ALF,11/26/2012,It was discovered that narcotic medications belonging to Resident #1 were missing from the medication cart. The theft of medications resulted from the actions of an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +DL121886,70M071,ALF,12/13/2012,"Resident #1 reported $1,700 missing from his/her wallet. An unknown individual was determined to be responsible for the theft of money. The facility failed to provide a safe environment resulting in the loss of property. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +DL132834,70M071,ALF,4/1/2013,Resident #1 stated that Reported Perpetrator 2 (RP2) asked him/her for their narcotic pain medication on more than one occasion. Resident #1 gave RP2 the medication. RP2 was found responsible for theft of narcotics which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +DL132930,70M071,ALF,4/11/2013,Reported Perpetrator 2 (RP2) approached Resident #1 and asked for a loan. Resident #1 agreed to loan RP2 $115.00. RP2 did not repay the loan. RP2 was found responsible for financial exploitation. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +DL133004B,70M071,ALF,3/31/2013,The facility failed to administer one of Resident #1_x001A_s medications as prescribed. Resident #1_x001A_s physician and family were notified. Resident #1 had no negative effects. The failure is a violation of Oregon Administrative Rules.,2,,,, +MM116213,70M072,ALF,12/29/2010,"Resident #1 had a known history of falls and increased confusion. The facility failed to adequately evaluate Resident #1's needs prior to providing care resulting in a fall with injury that required transportation to the hospital for treatment. The failure is violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM117389A,70M072,ALF,6/28/2011,"The facility failed to appropriately care plan after Resident #1 experienced a change of condition resulting in skin breakdown. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117721,70M072,ALF,8/3/2011,"Resident #1 had a history of cognitive decline that required assistance with ALDs (Activities of Daily Living). Resident #1 was observed to be in the same clothing for two days, smelled of urine and appeared to be unshaven. The facility failed to address Resident #1's change in condition and provide additional assistance resulting in inadeqaute hygiene. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM134087,70M072,ALF,8/8/2013,"Resident #1 was care planned to receive multiple services including transfer, bathing, toileting, peri care and dressing assistance. Resident #1 was transferred to the hospital and observed to have bruising of unknown origin and open wound on peri area. Witness testimony revealed Resident #1 expressed being in pain and had increased aggressive behaviors. Resident #1's care plan failed to address pain and behaviors. The facility failed to assess, care plan and appropriately monitor after significant changes of conditions. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MM149402,70M072,ALF,11/26/2014,"The facility failed to appropriately issue a move out notice after refusing to readmit Resident #1 from the hospital when discharged. The failure is a violation of resident rights, is considered emotional abuse and constitutes abuse.",2,,,,Verbal/Mental abuse +MM152888A,70M072,ALF,9/18/2015,"On or about September 18, 2015 RP2 administered 90 units of short-acting insulin to RV1 in error. RV1's physician orders were on a sliding scale for 90 units of long-acting insulin. RV1's blood sugar levels plummeted and he/she was transported to the hospital. RV1 was diagnosed with Accidental Insulin Overdose. RV1 returned to the facility the following day with a temporary service plan in place.",3,,Not Substantiated,Substantiated,Neglect +BC116086,70M073,ALF,12/20/2010,The facility failed to have medication available for Resident #1's regularly scheduled narcotic medications resulting in him/her missing four doses.,2,0,,, +BC116265B,70M073,ALF,12/23/2010,The facility failed to adequately conduct a facility investigation or notify Adult Protective Services of possible theft.,2,0,,, +BC120908,70M073,ALF,8/20/2012,The facility failed to perform an adequate screening and evaluation at move-in for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC132205,70M073,ALF,1/16/2013,"The facility failed to obtain a physician's order for the use of a heat pack for Resident #1. He/she suffered a burn blister. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC134835,70M073,ALF,9/28/2013,"Resident #1 missed four doses of a pain medication over a two day period, resulting in pain and withdrawal symptoms. There was no indication the facility was doing anything to relieve Resident #1's pain until requesting an emergency prescription two days later. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC152987,70M073,ALF,9/28/2015,Resident #1's care plan was not followed at the time of his/her non-injury fall. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +BC154118,70M073,ALF,12/28/2015,The facility failed to assure coordination with Resident #1's physician for receipt of information regarding any medication changes to ensure his/her medication administration record was accurate for administering medications as ordered. Resident #1's physician discontinued a medication on 10/23/15; however it was not discovered until 12/16/15. The facilities failures are a violation of resident rights and violate Oregon Administrative Rules.,2,,,, +AL129382,70M074,ALF,6/20/2011,"Beginning 6/20/11 thru 7/5/11, Residents #1 - #6 reported money missing from their apartments ranging from $20 to $200. The facility failed to immediately report to LEA or SPD and failed to take immediate measures to prevent further thefts. The failure is a violation of residents rights, is considered financial exploitation and constitutes abuse.",3,300,,,Financial abuse +AL129586,70M074,ALF,7/8/2011,"Resident #1 reported money had gone missing a couple of weeks prior and then discovered more money missing on 7/8/11. The facility had six other residents within the past month suffer theft of money. The facility failed to provide a safe environment and failed to take immediate measures to prevent further thefts. The failure is a violation of residents rights, is considered financial exploitation and constitutes abuse.",2,250,,,Financial abuse +AL132291,70M074,ALF,10/31/2012,"On 10/31/12 at about 5:30am, Resident #1 awoke to find Reported Perpetrator 2 (RP2) going through his/her pant pockets. RP2 left the room and Resident #1 discovered money missing from his/her pant pockets. Preponderance of evidence suggests that RP2 stole Resident #1's money, thus finding RP2 responsible for theft. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +AL151950,70M074,ALF,3/6/2015,"RV1 keeps a collection of notebooks and records where he/she documents daily events such as medication administration. On March 2, 2015 RV1 took a prescribed narcotic pain medication and counted 58 pills remaining in the bottle. RV1 was ill on March 3, 2015 and requested RP2 to retreive a pain pill from his/her locked drawer. RP2 accessed the locked drawer and retreived the pill for RV1. Due to illness, RV1 was transported to the hospital for evaluation but returned to the facility the same day. During the time that RV1 was out of the facility, RP2 was observed on surveillance video entering RV1's room and then exiting fifteen minutes later carrying a paper cup. RP2 is also seen on video surveillance concealing the cup before entering a restricted staff area. On March 5, 2015 RV1 discovered approximately 37 prescription narcotic pills were missing from the bottle in his/her locked drawer. The facility failed to provide a safe and secure enviroment.",3,,Not Substantiated,Substantiated,Financial abuse +AL152396,70M074,ALF,1/28/2015,RV1 experienced discomfort when being transferred by RP2. Facility documentation indicates that RV1 expressed his/her concerns regarding painful transfers and adjustments while in bed on three separate occasions. The facility failed to provide a safe and homelike environment. The facility's failure is a violation of the Oregon Administrative Rules.,2,,,, +CO12134,70M075,ALF,11/15/2012,"The facility failed to consistently evaluate and monitor, and failed to provide an RN assessment of skin breakdown and provide direction to staff for Resident #2. He/she experienced worsening of skin breakdown. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH121358,70M075,ALF,10/12/2012,"Resident #1 discovered cash money missing. An unknown person is responsible for the loss of money, constituting abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +BH121492,70M075,ALF,10/30/2012,"Resident #1 discovered cash money missing. An unknown person is responsible for the loss of money, constituting abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +BH121672,70M075,ALF,11/19/2012,"Resident's #1-4 discovered cash money missing. An unknown person is responsible for the loss of money, constituting abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",0,0,Not Substantiated,Substantiated,Financial abuse +BH133134,70M075,ALF,5/1/2013,Resident #1 discovered money missing from his/her wallet. An unknown person is responsible for the theft of money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +SV117865,70M076,ALF,8/30/2011,RP2 administered Resident #1 another resident's medications. Resident was monitored and several hour later was sent to the hospital for not feeling well. Physician indicated side effects of the medication would have shown up within four hours. The facility failed to provide a safe medication administration system resulting in the potential for harm.,2,0,,, +CO12132,70M076,ALF,10/4/2012,"The facility failed to evaluate, monitor, and refer to the facility RN changes of condition and failed to ensure the RN assessed Resident #1 related to his/her pain. Resident #1 suffered unrelieved pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV132258,70M076,ALF,1/24/2013,"Resident #1 and Resident #2 were both alert and oriented, and self managed their own medications. Both residents discovered missing medications from their apartments; however they were not found after a search in their apartments. An unknown individual is responsible for theft of medications. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",0,0,Not Substantiated,Substantiated,Financial abuse +CO13046,70M076,ALF,3/28/2013,"The Facility failed to ensure there were evaluations, monitoring, and development of interventions for Resident #14 who experienced a significant change of condition. Resident #14 experienced a fracture after a series of falls. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MV133444,70M076,ALF,6/6/2013,"Reported Perpetrator 2 (RP2) left Resident #1's call pendant on the bathroom counter after assisting him/her with an evening shower. Resident #1 got up, attempted to get the call pendant and ended up on the floor where he/she stayed all night and was found in the morning. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. RP2 is responsible for causing unreasonable discomfort to Resident #1, which is considered neglect and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +MV133380,70M076,ALF,4/1/2013,"During an audit by the facility pharmacy, it was discovered that Resident #1's diabetic medication was discontinued between April 1st, and May 28th, 2013 without a physician's order, resulting in the pharmacy dropping the order from Resident#'1s Medication Administration Record. The facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +MV150191,70M076,ALF,2/9/2015,"On February 9, 2015, RV1 returned to the facility from the hospital. RV1's call button was not placed on his/her bed as indicated in his/her care plan. RV1 attempted a self-transfer by using his/her wheelchair and suffered a laceration requiring transport to the hospital and six stitches on his/her finger. The facility's failure to follow RV1's care plan and provide a safe and secure environment is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV153681,70M076,ALF,11/22/2015,The facility failed to properly plan care to ensure Resident #1 was assisted to stand without pulling his/her arms/wrists. The failure is a violation of resident rights and Oregon Administrative Rules.,2,,,, +CO11045,70M077,ALF,3/4/2011,"The Facility failed to evaluate, monitor and provide an RN assessment resulting in skin breakdown to Resident #1 who experienced a pressure ulcer and developed an additional pressure ulcer. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB116746,70M077,ALF,4/7/2011,Resident #1 was care planned as a fall risk and staff were to check on him/her every two hours. Resident #1 had fallen in the night and didn't have his/her alert bracelet on. Staff did not check on him/her for approximately twelve hours during the night. Resident #1 suffered unreasonable discomfort and was cleared of injuries at the hospital.,2,0,,,Neglect +HB132226,70M077,ALF,1/24/2013,The facility failed to follow Resident #1's care plan resulting in a non-injury fall. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB132470,70M077,ALF,2/19/2013,The facility failed to provide a safe environment and did not timely answer Resident #1's call light. He/she had a non injury fall while attempting to use the bathroom unassisted. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB145679,70M077,ALF,1/13/2014,"A ring belonging to Resident #1 was stolen by an unknown individual. This person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB147243,70M077,ALF,5/29/2014,"The facility failed to care plan appropriately for Resident #2's and Resident #1' falls. Resident #2 had multiple falls and Resident #1 suffered two falls requiring hospitalization. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB147628,70M077,ALF,7/7/2014,"Resident #2 had physical altercations with Resident #1. The facility failed to intervene with Resident #2's physical behavior to provide a safe environment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB147577,70M077,ALF,6/27/2014,"Resident #1 had increasing behaviors during times when Reported Perpetrator 2 (RP2) was present and also times when RP2 was not present. His/her care plan did not address any factors of his/her behaviors nor implement interventions to ensure Resident #1 was free from harm. Resident #1 experienced unreasonable agitation. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB150648,70M077,ALF,3/23/2015,Resident #1 had $4000 stolen from his/her room. Preponderance of the investigation determined that Reported Perpetrator 3 (RP3) stole Resident #1's money. RP3's actions are considered financial exploitation which is abuse. The facility failed to provide a safe environment and violates Oregon Administrative Rules.,4,,Not Substantiated,Substantiated,Financial abuse +MV105844,70M078,ALF,10/3/2010,The facility failed to provide a safe environment resulting in the loss of Resident #1's money. Facility notified appropriate parties; and moved Resident #1's lockbox and replaced her/his lock for easier access. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV105898,70M078,ALF,10/15/2010,The facility failed to provide a safe environment resulting in the loss of money from several residents' rooms. The failure is a violation of Oregon Administrative Rules. Facility put new measures in place to assist in preventing future theft incidents.,2,0,,, +MV117828,70M078,ALF,8/25/2011,Resident #1 reported $20 and a camera missing. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown person was apportioned the abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MV120376,70M078,ALF,6/26/2012,Resident #1 was found with $40.00 missing from her/his wallet. Resident #1 is blind and gave W3 her/his wallet to retrieve $10.00 for a haircut. W3 indicated there were several bills in the wallet. The facility failed to provide a safe environment resulting in loss of money from Resident #1. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for financial exploitation and is considered abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MV121431,70M078,ALF,10/25/2012,"Resident #1 reported missing $1000 from her/his room that was unable to be located and police were notified. The facility failed to ensure a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",3,0,Not Substantiated,Substantiated,Financial abuse +MV120307,70M078,ALF,5/25/2012,"Resident #1 was out of the facility for a few days in the hospital. When Resident #1 returned, $60 was missing from his/her lock box. An unknown individual was responsible for the loss of Resident #1_x001A_s money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +MV121490,70M078,ALF,10/24/2012,"Resident #1's care plan stated he/she required assistance when transferring from his/her wheelchair to bed. Reported Perpetrator 2 (RP2) failed to provide hands-on assistance while Resident #1 transferred from his/her wheelchair to the bed, resulting in Resident #1 falling and fracturing a rib. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 failed to follow Resident #1's care plan, which is considered neglect of care and constitutes abuse.",3,0,Not Substantiated,Substantiated,Neglect +MV134166,70M078,ALF,7/22/2013,"Resident #1's debit card was missing from 07/20/13 - 07/22/13 and purchases were found on the card that were made by someone other than Resident #1, as he/she hadn't left the facility on those days. Resident #1 gave Reported Perpetrator 2 (RP2) his/her pin number so RP2 could shop for Resident #1. RP2 stated he/she made a purchase at Fred Meyer for Resident #1. In addition to Fred Meyer, there is a purchase at a liquor store on the same date and another purchase 2 days later at another store. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for financial exploitation, which constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +MV145811,70M078,ALF,1/17/2014,"Reported Perpetrator #2 (RP2) gave incorrect medication to Residents #1, 2, 3, 4, 5, 6, and 7. Resident #4 missed his/her pain medication and indicated increased pain as a result. RP2 was found to be responsible for neglect of care which constitutes abuse. The facility failed to maintain a safe medication administration system, which is also neglect of care and constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,Substantiated,Substantiated,Neglect +MV148446,70M078,ALF,8/13/2014,"The facility failed to adequately arrange transport for Resident #1, resulting in him/her missing several physician and other health appointments. This failure is a violation of Oregon Administrative Rules.",2,,,, +CO11039,70M079,ALF,3/15/2011,"License Condition based on a re-licensure survey completed on 3/15/11. Survey revealed multiple areas of concern including but not limited to, assessment and service planning, evaluations, documentation, change of condition and monitoring, medication administration system, and staffing. License Condition was issued on 4/12/11 after phone informal with the facility Administrator and facility RN.",3,0,,,Neglect +HM116583,70M079,ALF,3/16/2011,"Resident #1 was a fall risk that required a tab alarm 24 hours a day. Resident #1 experienced a pelvic fracture from an unwitnessed fall, without a tab alarm present. The facility failed to ensure staff monitored and reported Resident #1's ability to remove a tab alarm. The failure is a violation of OARs.",2,0,,, +HM116587,70M079,ALF,3/13/2011,"A Facility staff member, Reported Perpetrator #2 (RP2), was approached by a facility resident regarding the resident_x001A_s issues with the way the staff member was administering his/her medications. RP2 was overheard to yell at the resident. The Facility terminated RP2 following the incident.",2,0,,, +HM120043,70M079,ALF,5/6/2012,Resident #1 had a condition related to memory loss and was at risk for falls. Care plan directed staff to check on an hourly basis and have a tab alarm on the resident at all times. Resident #1 was found on the floor with a skin tear during hourly checks. RP2 failed to place the tab on Resident #1. The failure is a violation of Oregon Administrative Rules. RP2 was substantiated for neglect of care and constitutes abuse.,2,0,Not Substantiated,Substantiated,Neglect +HM120643,70M079,ALF,7/25/2012,"Resident #1 had a history of falls and required hourly checks, tab alarm and pull cord within reach. Staff discovered Resident #1 on floor with minor scratch from fall after attempting to self transfer. Resident #1 used the pull cord, but was disconnected. Resident #1's tab alarm was not in place at the time of the incident, however was known to pull it off without sounding the alarm. The facility failed to ensure a safe environment resulting in minor harm and potential for moderate harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HM134165,70M079,ALF,7/16/2013,Resident #1 was transported to the hospital for observation after she/he was given the wrong medications by RP2. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC129226,70M080,ALF,12/31/2011,"Reported Perpetrator 2 (RP2) signed out narcotics on the Narcotic Sheets for Resident #1, Resident #2 and Resident #3 for consecutive eight to eleven day periods, but not on the corresponding Medication Administration Record Sheets. Other staff and the three residents don't recall reports of pain or requesting medications to relieve pain. RP2 is responsible for the theft of narcotic medications. The facility failed to provide a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +BC129914,70M080,ALF,4/3/2012,Witness 1 stated that Reported Perpetrator 2 (RP2) yelled at Resident #1 and roughly pulled his/her socks off; however RP2 denied yelling or roughness. Resident #1 was assessed and did not show any signs or symptoms of abuse or emotional trauma. The facility failed to assure Resident #1 was treated with dignity and respect. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC121746,70M080,ALF,11/23/2012,Reported Perpetrator 2 (RP2) administered another residents_x001A_ medication to Resident #1; and RP2 failed to follow facility protocol when medication errors occur. Resident #1 did not suffer ill effects. The facility failed to provide a safe medication administration system.,2,0,,, +HB129038,70M081,ALF,1/24/2012,Resident #1 reported money missing from his/her wallet. An unknown individual was determined to be responsible for the theft of money. The facility failed to provide a safe environment for residents resulting in loss of property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated, +HB129242,70M081,ALF,2/14/2012,"Resident #1_x001A_s service plan indicated that the facility was responsible for administering and ordering his/her medication. Resident #1 did not receive his/her medications as prescribed, resulting in transportation to the hospital for treatment. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB129277,70M081,ALF,2/17/2012,Reported Perpetrator 2 (RP2) was verbally inappropriate with Resident #1 and Resident #2 was visably upset after the incident. The facility failed to provide a safe environment. RP2 was found responsible for abuse.,3,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HB129338,70M081,ALF,2/24/2012,Resident #1 reported money missing. An unknown individual was determined to be responsible for the theft of money. The facility failed to provide a safe environment for residents resulting in loss of property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB120099,70M081,ALF,5/20/2012,Resident #1 reported $70.00 missing from his/her wallet in his/her apartment. An unknown individual was responsible for financial exploitation which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,250,,, +HB129883,70M081,ALF,4/24/2012,"Resident #1 reported coins missing from a drawer in his/her apartment. + +An unknown individual was responsible for the loss of coins. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +HB120710,70M081,ALF,8/1/2012,Resident #1 reported his/her portable DVD player missing from his/her room. An unknown individual was determined to be responsible for the loss of the portable DVD player. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB120770,70M081,ALF,8/6/2012,"Resident #1 sustained a sunburn on his/her forearms from being outside all afternoon. Sunscreen was not applied to Resident #1_x001A_s arms. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB121770,70M081,ALF,11/17/2012,Resident #1_x001A_s bank card was stolen from his/her room while he/she was being transported to the hospital. Cash was also stolen from his/her lock box. Resident #2_x001A_s bank card was stolen from his/her room. Law Enforcement was notified. Video surveillance was obtained from one of the retailers showing Reported Perpetrator 2 (RP2) making purchases with Resident #1_x001A_s bank card. During RP2_x001A_s arrest he/she also admitted to taking and using Resident #2_x001A_s bank card. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +HB132430,70M081,ALF,2/17/2013,Resident #1 reported his/her ring that was on a necklace missing. An unknown individual was responsible for the loss of jewelry. The facility failed to provide a safe environment resulting in the loss of Resident #1_x001A_s property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB121770X,70M081,ALF,11/17/2012,Resident #1's bank card was stolen from his/her room while he/she was being transported to the hospital. Cash was also stolen from his/her lock box. Resident #2's bank card was stolen from his/her room. Law Enforcement was notified. Video surveillance was obtained from one of the retailers showing Reported Perpetrator 2 (RP2) making purchases with Resident #1's bank card. During RP2's arrest he/she also admitted to taking and using Resident #2's bank card. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB132687,70M081,ALF,3/18/2013,It was reported that Resident #1's watch was missing. An unknown individual was found responsible for the loss of Resident #1's watch. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB135176,70M081,ALF,11/25/2013,The facility failed to provide a safe medication administration system resulting in Resident #1 being administered the wrong dose of medication. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB146647,70M081,ALF,4/8/2014,Resident #1 reported $20 missing from his/her. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +HB147407,70M081,ALF,6/16/2014,Resident #1 was administered Resident #2's medications. Resident #2 was given the correct medications. Resident #1's physician directed facility to put him/her on alert monitoring for any side effects. Resident #1 experienced no negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB148070,70M081,ALF,8/8/2014,Resident #1 reported $100.00 missing from his/her room. Reported Perpetrator 2 (RP2) was identified by the facility as having been in Resident #1's room to provide bathing support. During this time RP2 was unsupervised. RP2 denied taking Resident #1's money and there was no further evidence to support the allegation. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +HB148402,70M081,ALF,9/4/2014,Resident #1 was administered medications that belonged to another resident. There was no negative outcome to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB159849,70M081,ALF,1/8/2015,Reported Perpetrator 2 (RP2) administered Resident #1 medication belonging to Resident #2 in error. Resident #1 experienced drowsiness. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB159761,70M081,ALF,1/2/2015,Resident #1 reported $100 gift card and $40.00 missing from his/her wallet. Reported Perpetrator 2 (RP2) was identified by store video surveillance using the gift card. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES117267,70M082,ALF,1/14/2011,A resident of the Facility whose services were to include medication management was not being provided assistance with his/her medications by Facility staff.,1,0,,, +ES117269,70M082,ALF,3/19/2011,A resident of the Facility that had cognitive issues was able to walk out of an alarmed door without being noticed by Facility staff. The resident had previously displayed behaviors and had successfully left the Facility unassisted on previous occasions. The resident was a known elopement risk.,1,0,,, +ES116204,70M082,ALF,1/25/2011,"The Facility failed to appropriately care plan and increase staffing to meet the needs of Resident #1_x001A_s increased elopement behaviors. Resident #1 eloped from the facility and the only caregiver on duty found him/her; however left the residents in the facility unattended for approximately ten minutes. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES129887,70M082,ALF,4/23/2012,"Resident #1 reported 100-150 pain pills, debit card, pocket knife and small amount of cash missing from his/her dresser drawer. Resident #1 was not informed of the availability of a locking cabinet nor given a key when he/she moved in. It was also discovered during the investigation that facility staff carry master keys even when off duty. An unknown individual was determined to be responsible for the theft of medications and money. The facility failed to provide a safe environment resulting in the loss of pain medications and property. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,Substantiated,Substantiated,Financial abuse +ES120205,70M082,ALF,5/17/2012,Resident #1 reported $150.00 missing from his/her room. Resident #1_x001A_s door did not lock for a period of time during which the money went missing. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES147360,70M082,ALF,6/10/2014,"Resident #1 had $1000 go missing from the facility safe. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation, and constititues abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES147453,70M082,ALF,6/18/2014,"Resident #1's money went missing out of the facility safe. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES146949,70M082,ALF,4/19/2014,"Resident #1 had $455 taken from the facilities secure lock box. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES148684,70M082,ALF,7/4/2014,"The facility failed to adequately assess, intervene, and monitor Resident #1 in relation to Resident #1's fall risk. Resident #1 was noted to need education to reduce fall risks in his/her service plan. However, no further documentation or assessment occurred. Resident #1 subsequently sustained an un-witnessed fall, and was sent to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care.",3,300,Substantiated,Substantiated,Neglect +ES159969,70M082,ALF,1/20/2015,"Resident #1 had money go missing from his/her room. The money was found to be taken by an unknown individual and this individual is responsible for theft of property, which is considered financial exploitation, and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES147491A,70M082,ALF,6/6/2014,"The facility failed to adequately monitor Resident #1, and left him/her outside for an extended period of time. This failure is a violation of Oregon Administrative Rules.",3,,,, +ES147491B,70M082,ALF,6/6/2014,The facility failed to administer Resident #1 medication as ordered. Resident #1 was not administered this medication for one day. This failure is a violation of Oregon Administrative Rules.,2,,,, +WB117640,70M084,ALF,7/25/2011,RP2 was observed being physically rough and yelling at Resident #1. The facility failed to protect Resident #1 from rough treatment resulting in harm.,2,0,Not Substantiated,Substantiated,Physical Abuse +WB129265,70M084,ALF,2/13/2012,"On or about February 13, 2012, multiple narcotic medication cards from three know residents were missing from the locked medication room. An internal investigation was conducted and local law enforcement notified. RP2 was suspected of the thefts, but not proven. The facility failed to provide a safe medication administration system resulting in the loss of medications. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for the theft.",2,0,Not Substantiated,Substantiated,Financial abuse +WB145718,70M084,ALF,12/11/2013,"Resident #1 had had money taken from their room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +WB148160A,70M084,ALF,8/6/2014,"Resident #1 required treatment by ambulance after she/he experienced shortness of breath. Investigative findings revealed RP2 was unable to administer Resident #1's nebulizer treatment due to floors being replaced. The facility failed to ensure medications were administered as ordered resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +WB149148,70M084,ALF,11/1/2014,"On or about November 2, 2014, multiple medication errors were discovered to have been made the evening prior. There was also a concern that residents were potentially not adequately cared for. Investigation concluded that the facility failed to ensure adequately trained staff were available to provide proper care resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +WB151473,70M084,ALF,6/1/2015,"Reported Victim #1 (RV1) requires assistance with administering medications and arranging transportation for medical appointments. RV1 has his/her INR blood tests done on a regular basis. RV1 missed his/her appointment on May 21, 2015. The facility failed to arrange for appropriate transportation for RV1's appointment. In addition, The facility failed to administer RV1's blood thinner medications on June 1, June 2 and June 3, 2015 creating a potential risk of harm for RV1.",2,,,, +MS116037B,70M085,ALF,12/18/2010,"A resident received allergy medication instead of his/her physician prescribed medication for a specific medical condition. The error occurred when the pharmacy sent the Facility the wrong medication; however the Facility did not verify the medications were correct upon receipt and prior to administration to the resident. The resident received the wrong medication for an extended period of time, which placed the resident at risk of harm.",2,0,,, +MS129984,70M085,ALF,5/6/2012,"Resident #1 was care planned to wear incontinent briefs provided by the facility, he/she was on a two hour toileting schedule, and daily emptying of his/her garbage. He/she was out of incontinent products, and he/she was discovered urine soaked, bed and bedding soaked and the garbage can compacted and overflowing with soiled incontinence briefs. The facility failed to follow the care plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +MS120965,70M085,ALF,8/30/2012,Resident #1 was an accurate historian and kept his/her door locked when not in the room; however he/she discovered two $20 bills removed from his/her wallet. An unknown individual is responsible for the loss of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MS132504A,70M085,ALF,2/26/2013,Resident #1 reported $75.00 missing from his/her wallet in his/her apartment. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated, +MS133271,70M085,ALF,4/2/2003,Resident #1 was administered medication belonging to another resident. Resident #1 was sent to the hospital per his/her physician_x001A_s request for monitoring. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS132907,70M085,ALF,4/3/2013,"Resident #1 was transported to the hospital complaining of not feeling well and was admitted with heart problems. Resident #1's medication was discontinued in error due to another resident having the same first name. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS133302,70M085,ALF,5/26/2013,Resident #1 reported money missing from his/her wallet. An unknown individual is responsible for the loss of Resident #1_x001A_s property. The facility failed to provide a safe environment for Resident #1 resulting in the loss of money. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MS134960,70M085,ALF,11/4/2013,Resident #1 and Resident #2 were involved in an altercation. Resident #2 rammed his/her ambulation device into Resident #1. No injuries were sustained. Resident #2 has a history of aggression. The facility failed to address Resident #2's behavior. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS135328,70M085,ALF,12/9/2013,"Resident #2 had a history of physical aggression towards others. The facility failed to update Resident #2's service plan with interventions to prevent physically aggression or monitor Resident #2 for agitation. This failure is considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS148817A,70M085,ALF,10/5/2014,Resident #1 requested assistance using the restroom. The facility failed to timely respond to Resident #1's request for assistance. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS148817B,70M085,ALF,10/5/2014,It was reported that the facility failed to protect Resident #1 from inappropriate comments made by staff members. The facility failed to assure Resident #1's rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS149608,70M085,ALF,8/21/2014,Resident #1 was involved in an altercation with Resident #2. No injuries were sustained. Resident #1 had a history of incidents involving both staff and residents. The facility failed to address Resident #1's behaviors regarding other residents. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS152897,70M085,ALF,7/20/2015,Resident #1's credit card was reported missing. Reported Perpetrator 2 (RP2) admitted taking and using Resident #1's credit card. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MS152345,70M085,ALF,8/5/2015,"Resident #1 moved into the facility on July 28, 2015. Resident #1 did not receive two of his/her prescribed medications between July 28, 2015 and August 5, 2015. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS153192,70M085,ALF,9/8/2015,"Resident #1 had a history of falls with injury. There was no documentation regarding Resident #1 being checked on or what assistance was provided from 6:45 am until 12:30 pm when he/she was transported to the hospital. Resident #1 sustained a fractured femur. The facility failed to care plan regarding fall interventions. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This incident warrants a civil penalty; however, due to the fact that the facility had a change in ownership a civil penalty will not be issued.",3,,,,Neglect +MS153373,70M085,ALF,11/2/2015,"Resident #1 was prescribed a narcotic pain medication to be administered as needed. On October 28, 2015, Resident #1 requested pain medication in the evening and was told by Reported Perpetrator 2 (RP2) that it was too soon to have another dose. Resident #1 reported that he/she had not requested pain medication that day. RP2 claimed to administer Resident #1's medication routinely, rather than as needed. The facility failed to provide a medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS153589,70M085,ALF,11/17/2015,Resident #1 was prescribed a narcotic medication. Resident #1's narcotic pain medication was not stored in a locked area while it was in facility staff's possession. Six narcotic pills were missing from the bottle. An unknown individual was found responsible for the loss of Resident #1's medications which constitutes financial exploitation. The facility failed to provide a safe environment and provide a system that prevents theft or misuse of medications. The failures are a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +CO14056,70M086,ALF,2/6/2014,"The facility failed to ensure service plans were reflective of resident needs, were completed within eight hours of admission and reviewed within thirty days after admission. The facility also failed to ensure residents who experienced short term change of conditions were monitored. Resident #3_x001A_s service plan was not accurate and he/she continued to experience swelling of his/her ankle due to strap on catheter being too tight. Resident #1 experienced skin tears as a result of a fall with no further interventions. Resident #3 experienced a worsening foot wound. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +NW146686,70M086,ALF,2/21/2014,"The facility failed to implement interventions to ensure Resident #1 received two person transfer assistance as stipulated in his/her care plan. Resident #1 injured his/her arm during a fall when Witness #7 attempted to transfer Resident #1 by themselves. This is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +NW146690,70M086,ALF,2/21/2014,"The facility failed to implement interventions to ensure Resident #1_x001A_s spouse received two person transfer assistance as stipulated in his/her care plan. Resident #1 injured his/her shoulder during a fall when he/she attempted to transfer his/her spouse without additional assistance. This is a violation of resident rights, is considered neglect of care, and constitutes abuse.",3,300,,,Neglect +ST116172,70M087,ALF,1/19/2011,Resident #1 had jewelry stolen from apartment on 1/19/11. RV2 had jewelry stolen from apartment one month prior; however the facility failed to report or investigate the theft after notified. Staff were the only ones with keys to all residents rooms.,2,0,,,Financial abuse +ST121437,70M087,ALF,10/26/2012,"Resident #1 was care planned requiring staff assistance transferring on and off the toilet and was required to use call cord or pendant for assist. On 10/23/12, the facility failed to timely answer his/her call light in a timely manner. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ST135073,70M087,ALF,11/14/2013,"The facility failed to provide medication as ordered for three separate residents. Resident #1 failed to receive medication for twelve days, Resident #2 for twenty seven days, and Resident #3 for thirty nine days. This failure is a violation of Oregon Administrative Rules.",2,,,,Neglect +ST135221,70M087,ALF,11/19/2013,"Reported Perpetrator 2 gave Resident #2's medication to Resident #1 in error. Facility staff appropriately assessed and monitored Resident #1 after the error occurred, and Resident # 1 did not appear to suffer any effects. However, the facility failed to ensure a safe medication administration system. This failure is a violation of Oregon Administrative Rules.",2,,,, +ST152281,70M087,ALF,7/20/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES118344,70M088,ALF,10/28/2011,"RP2 was training RP3, who administered the wrong medication to Resident #1. RP2 set up the residents' medications, but had RP3 administer them to residents. The facility failed to ensure medication was administered as ordered resulting in the potential for harm.",2,0,,, +ES133974,70M088,ALF,7/26/2013,"The facility failed to assure timely medical treatment after Resident #1 experienced a body rash resulting in the medical condition worsening. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES148745,70M088,ALF,9/29/2014,Complainant reported RP2 was physically rough when providing toileting assistance with Resident #1. RP2 was observed to forcefully grab the resident's hands and arms and physically pry her/his fingers from the grab bar. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +ES149138,70M088,ALF,11/4/2014,"Complainant reported money missing from Resident #1's room. RP2 was suspected, but it was unable to be determined who took the money. The facility failed to ensure a safe environment. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES150163,70M088,ALF,2/6/2015,"The facility failed to ensure Resident #1 received continuous oxygen use when transported to a medical appointment. As a result, Resident #1's oxygen level was low and had to be transported back to the facility by ambulance. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +ES151050,70M088,ALF,4/22/2015,"Resident #1 reported money missing from her/his room. The facility failed to ensure a safe environment resulting in the loss of resident property and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES150917,70M088,ALF,4/12/2015,"The facility failed to adequately care plan and monitor Resident #2's inappropriate behavior resulting in unwanted sexual touching of Resident #1. The failures are a violation of resident rights, is considered neglect of care resulting in sexual abuse.",2,,,,Neglect +ES151573,70M088,ALF,5/28/2015,Resident #1 had an order for staff to provide wound care twice daily. Witness testimony revealed that the facility failed to provide services as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES152646B,70M088,ALF,8/29/2015,"On August 29, 2015 at approximately 8:30 a.m. a verbal incident between RP2 and RV1 ocurred in the dining room of the facility. RP2 was observed by staff and other facility residents raising his/her voice to RV1 and directing RV1 to get his/her assistive device out of the dining area. On September 3, 2015 RP2 stated he/she was louder with RV1 and that he/she was stressed out on the day of the incident. The facility failed to provide a safe and secure environment which is a violation of the Oregon Administrative Rules.",2,,,, +FL129289,70M089,ALF,2/12/2012,"Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) did not use a gait belt to transfer Resident #1 to the toilet and he/she fell to the floor. Resident #1 complained of pain, was transported to the hospital and diagnosed with a fractured femur. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 and RP3 are found responsible for neglect of care resulting in harm to Resident #1.",3,0,Not Substantiated,Substantiated,Neglect +FL133428,70M089,ALF,6/5/2013,"Resident #1 threw hot coffee on Resident #2 on one occasion and hit Resident #2 twice on another occasion. The first incident was not documented or reported and no interventions were implemented, even though Resident #1 was being treated for an infection that is known to sometimes cause behavioral issues. The facility failed to address a resident's behavior. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +FL146466,70M089,ALF,3/24/2014,Complainant reported approximately $750 missing from a total of five residents' personal incidental funds held by the facility. RP2 was responsible for the money at the time the investigation took place and failed to properly notify appropriate parties upon discovery. All residents' monies were reimbursed. The facility failed to ensure a safe environment resulting in loss of resident money. RP2 was held responsible for financial exploitation and constitutes abuse.,3,,Not Substantiated,Substantiated,Financial abuse +FL149119A,70M089,ALF,11/1/2014,"Resident #1 was alert and oriented and was care planned for stand by assist for toileting. Reported Perpetrator 2 (RP2) left his/her room and did not stand and assist Resident #1 to the restroom, exposing him/her to harm. Resident #1 was not treated with respect and dignity. The facility failed to ensure Resident #1's care plan was followed and is a violation of Oregon Administrative Rules.",2,,,, +ES147310,70M089,ALF,6/2/2014,"Reported Perpetrator 2 (RP2) was found responsible for the theft of money from Resident #5, Resident #6, and Resident #4 totaling approximately $70. An unknown individual was found responsible for the theft of money from Resident #1, Resident #2, Resident #3, and Resident #4 totaling approximately $790. Theft of money is considered financial exploitation and constitutes abuse. The facility failed to ensure a safe environment and violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +FL148643,70M089,ALF,9/22/2014,"Reported Perpetrator 2 (RP2) was harsh in his/her communication style when providing care to Resident #1, Resident #2 and Resident #3. RP2 did not treat residents with dignity and respect. The facility failed to provide a safe and homelike environment and the failure violates Oregon Administrative Rules.",2,,,, +ES152982,70M089,ALF,9/30/2015,"Resident #1 reported personal items missing. An investigation was conducted and determined an unknown individual is responsible for the theft of items, which constitutes abuse. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +FL164284,70M089,ALF,1/13/2016,Resident #1's medications were left in a medication cup on his/her tray rather than staff observing him/her take the medications. He/she had no negative side effects. The facility failed to ensure a safe medication administration system which violates Oregon Administrative Rules.,2,,,, +ES164346,70M089,ALF,12/25/2015,Resident #1 was administered an over-the-counter bedtime medication at 12noon in error. There were no negative side effects. The facility failed to ensure a safe medication administration system which violates Oregon Administrative Rules.,2,,,, +DL151791,70M091,ALF,4/18/2015,"The facility ordered a new medication that required a lab test one week after administration. The facility did not order the lab work and the test was not completed. Resident #1 experienced increased weakness and chest pain over the next two months and was transferred to the hospital for treatment. The facility failed to evaluate and refer Resident #1's significant change of condition to the RN. The facility also failed to ensure a safe medication administration system. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AS105902,70M092,ALF,12/3/2010,"A resident of the Facility left his/her bag in the dining room of the Facility by mistake. Facility staff returned the resident's bag the following morning. During the time the resident did not have his/her bag in his/her possession, somebody removed the resident's money from the bag.",2,0,,, +AS105974,70M092,ALF,12/16/2010,The Facility failed to provide an environment in which Resident #1 was free from the loss of his/her personal resources.,2,300,,,Financial abuse +AS116196,70M092,ALF,1/18/2011,"A Facility staff member, Reported Perpetrator #2 (RP2) admitted to taking a residents wallet from his/her room and using his/her credit card multiple times, charging approximately $300.00 to the residents charge account. RP2's actions were not consistent with Facility policy and upon discovery of his/her actions, the staff member was terminated.",2,0,Not Substantiated,Substantiated,Financial abuse +AS117554,70M092,ALF,7/25/2011,Resident #1 reported missing 6 rings. An investigation was initiated and LEA contacted but were unable to locate the missing items. The facility failed to provide a safe environment resulting in the loss of Resident #1's property. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +AS118663,70M092,ALF,12/6/2011,"On December 6, 2011, Resident #1 reported his/her narcotic medications missing from room. The theft of narcotic medications resulted from an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for financial exploitation.",2,0,Not Substantiated,Substantiated,Financial abuse +AS120169,70M092,ALF,5/29/2012,"Resident #1_x001A_s care plan indicated that the facility was responsible for administering and documenting his/her medications in the Medication Administration Record (MAR). Due to a documentation error on the MAR, Resident #1 did not receive 3 dosages of his/her medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AS121155,70M092,ALF,9/18/2012,"Resident #1 was being transported back to the facility in the facility bus and his/her wheel chair fell over. Resident #1 sustained a broken neck. Resident #1_x001A_s wheel chair was not strapped into the bus. The facility driver was not trained to or required to strap in electric wheel chairs when transporting a resident. The facility failed to ensure safe transportation for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +AS133372,70M092,ALF,5/31/2013,Resident #1 reported $320.00 missing from his/her room. The facility reimbursed Resident #1. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +AS135019,70M092,ALF,11/6/2013,Resident #1 reported $238.00 missing from his/her room after receiving help with a shower. RP2 (Reported Perpetrator 2) admitted taking the money. RP2 returned to money through law enforcement. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +AS145882,70M092,ALF,12/31/2013,Resident #1 reported $50.00 missing from his/her room. An unknown individual was responsible for the loss of Resident #1's money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +AS135359,70M092,ALF,12/10/2013,Resident #1 reported $140.00 missing from his/her room. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment for residents. The failure is a violation of resident rights.,2,300,Not Substantiated,Substantiated,Financial abuse +AS146523,70M092,ALF,3/23/2014,Resident #1 reported $40.00 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +AS145866,70M092,ALF,1/23/2014,"Resident #2 entered Resident #1's room and hit Resident #1 several times. Resident #1 was transported to the hospital with multiple injuries. Resident #1 sustained bruising and lacerations on his/her face and head. The facility failed to implement interventions to address Resident #2's behavior or update Resident #2's care plan regarding wandering. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +AS145948,70M092,ALF,1/28/2014,"RP2 falsified Resident #1's Medication Administration Record and did not provide the resident with her/his medication. Resident #2's narcotic medications were replaced with Tylenol. The were no physically negative outcomes as a result. RP2 was found responsible for theft of Resident #1's medication, is considered financial exploitation and constitutes abuse. It is suspected, but not confirmed that RP2 is also responsible for the loss of Resident #1's medication. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +AS149725,70M092,ALF,12/5/2014,"Resident #1 reported jewelry missing from her/his apartment. The incident was reported and an internal investigation was unable to locate a suspect. Investigation concluded the facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is consider financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +AS159870,70M092,ALF,12/24/2014,"Resident #1 reported jewelry missing from her/his room. The incident was reported and the room was searched with no luck. An investigation was unable to determine who took the item. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +AS150104,70M092,ALF,1/30/2015,"The facility failed to ensure a safe environment resulting in the loss of money from Resident #1. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BH116738,70M093,ALF,11/29/2010,"Due to Resident #1's behaviors, he/she was sent to the hospital for evaluation and was discharged to return back to the facility; however the facility refused readmittance and failed to properly provide a move-out notice.",1,0,,, +BH132615,70M093,ALF,3/9/2013,The facility failed to have Resident #1's medication available resulting in him/her missing one day worth of medication. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BH153613,70M093,ALF,7/24/2015,"Resident #1 had a history of wandering at night both inside and outside of the facility. On 2/14/15, he/she left the facility and was located approximately 100 yards from the facility. On 7/24/15, he/she left the facility and was located approximately 300 yards from the facility and had minor injuries. The facility failed to implement interventions and care plan appropriately regarding his/her behaviors to ensure safety. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +AL146526,70M095,ALF,9/1/2013,Resident #1 did not receive a prescribed medication for a month. Resident #1 did not experience any harm as a result. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL164555,70M095,ALF,11/3/2015,Resident #1 reported between $50.00 and $100.00 missing from his/her wallet. The wallet was in his/her room while he/she went to the dining room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RD116702,70M096,ALF,3/1/2011,The facility failed to ensure Resident #1's narcotic medication order was processed timely and available per physician's orders. Resident #1 did not get his/her ordered narcotic medication on 3/7/11; however he/she was administered his/her PRN narcotic medication to help with the pain.,2,0,,, +RD118056,70M096,ALF,8/14/2011,Resident #1 had a physician_x001A_s order stating h/s was to get two doses of anti-seizure medication. There was a transcription error on h/s Medication Administration Record (MAR) which resulted in Resident #1 only getting one dose for three weeks.,2,0,,, +RD118669,70M096,ALF,11/27/2011,The facility failed to have a safe medication administration system to ensure Resident #1's prescribed medication was available and administered at the prescribed times. Resident #1 missed the 9am dose on 11/25/11 and missed the 9pm dose on 11/27/11.,2,0,,, +RD120814,70M096,ALF,7/7/2012,"Resident #1 needed assistance and Reported Perpetrator 2 became frustrated and each ""exchanged words."" The facility failed to ensure Resident #1 was treated with dignity and respect. The failure is a violation of Oregon Administrative Rules.",2,0,,, +RD121412,70M096,ALF,10/7/2012,Resident #1 suffered a skin tear during care provided roughly by Reported Perpetrator 2 (RP2). RP2 is responsible for physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +RD132268,70M096,ALF,1/24/2013,"While providing care to Resident #1, Reported Perpetrator 2 (RP2) pushed on Resident #1's arms to keep him/her in the same position. Resident #1 cried and had red marks on his/her arms. RP2 is found responsible for physical abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +RD133631B,70M096,ALF,5/12/2013,"Resident #2's Service Plan stated he/she had chronic pain in his/her legs and feet. On 05/24/13, a new medication for Resident #2's leg pain was delivered to the facility but did not get logged in as received. Resident #2 did not receive the medication until four days later on 05/28/13, resulting in unreasonable comfort. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD133631C,70M096,ALF,5/12/2013,"Resident #3 fell, hit his/her head and was on the floor for 45 minutes before staff responded. Resident #3 stated he/she was unconscious for a time and had pain in his/her neck. He/she was transported to the hospital. No injuries were reported. The facility failed to answer Resident #3's call light in a timely manner, resulting in unreasonable discomfort to Resident #3. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RD134021B,70M096,ALF,7/1/2013,"Resident #2's Medical Administration Record (MAR) for July, 2013 did not match the physician's order. The error on the MAR was caught by staff and changed by the staff writing over the original number with the correct number. Once the change was made, the amount should have read 10 units of insulin but looked like 40, resulting in Resident #2 receiving 40 units of insulin two days in a row. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,,Neglect +RD135105,70M096,ALF,9/26/2013,"Resident #1 and two staff witnesses stated Reported Perpetrator 2 (RP2) was rough while handling Resident #1. RP2 stated he/she was ""forceful"" and pulled on Resident #1's shoulders and lower back. Resident #1 stated he/she asked RP2 on many occasions not to be so rough, which RP2 corroborated. The facility failed to protect Resident #1 from rough treatment, which is a violation of Oregon Administrative Rules. RP2 is responsible for physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +BO135338,70M096,ALF,11/14/2013,The facility failed to ensure Resident #1's medications were available to administer per physician orders. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO153869,70M096,ALF,10/7/2015,The facility allegedly failed to provide a safe environment for Resident #1 and Resident #2. An investigation determined no facility wrongdoing was identified.,0,,,, +JD120085,70M098,ALF,4/22/2012,"Resident #1 was a known fall risk and care planned for staff to _x001A_accompany outside due to unsteady gait and risk of fall._x001A_ On or about May 22, 2012, Resident #1 was found alone outside on the ground and complaining of neck pain from a fall. The resident was transported to the hospital and diagnosed with C1 and C2 (neck) fractures. The facility failed to appropriately monitor and follow the care plan resulting in serious harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,2500,,,Neglect +JD133601A,70M098,ALF,5/11/2013,Reported Perpetrator 2 (RP2) helped Resident #1 up by offering an arm for Resident #1 to pull his/her self up. Resident #1 experienced pain after the transfer. Resident #1's service plan states that staff are to place their arms under Resident #1's arms to assist him/her to stand. The facility failed to follow Resident #1's service plan. The failure is a violation of Oregon Administrative Rules.,2,,,, +JD133601B,70M098,ALF,5/11/2013,It was reported that the facility failed to provide a respectful environment. Resident #1 was upset with his/her interaction with Reported Perpetrator 2 (RP2) and requested that RP2 no longer assist him/her due to rudeness. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +JD135006,70M098,ALF,7/8/2013,"Resident #1 did not receive 10 doses of his/her inhaled medication due to the nebulizer not working properly. Resident #1 was transported to the hospital due to shortness of breath. The facility failed to provide a safe medication administration system and train staff appropriate. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +JD135008,70M098,ALF,3/11/2013,Resident #1 reported $400.00 missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +JD135009,70M098,ALF,6/27/2013,"Resident #1 had not been administered medication per his/her physician's orders. He/she discovered the call light was inoperative when Resident #1 tried to contact staff due to having shortness of breath. Resident #1 used his/her cell phone to contact Witness #4 for help. Witness #4 contacted staff by phone. The facility failed to have a safe medication administration system resulting in Resident #1 not receiving his/her medication. The facility also failed to have an operable call light system. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +JD145785,70M098,ALF,1/12/2014,The facility failed to administer Resident #1's medication according to physician's orders. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +JD121831,70M098,ALF,8/23/2012,Resident #1 had a medical diagnosis that required specific dietary needs to maintain his/her weight. The facility failed to assure Resident #1's resident rights regarding acceptable foods for his/her dietary needs. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH146155,70M099,ALF,1/31/2014,"Complainant reported multiple residents' money was missing from a lockbox maintained by the facility and money missing from several residents' rooms. In all instances, it apears that the locks to access the money was tampered with. Facility notified local law enforcement and conducted an internal investigation. RP2 and RP3 were suspected, however it was unable to be determined who was responsible for the theft of money. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +HB117015,70M100,ALF,5/4/2011,RP2 was verbally inappropriate with Resident #1 when the resident called out her/his name. The facility failed to ensure Resident was treated with dignity and respect resulting in a loss of dignity. The failure is a violation of OARs.,2,0,,, +HB129484,70M100,ALF,3/12/2012,"Resident #1 had known skin issues that required staff to be very gentle with all care transfers and positioning. On March 11, 2012, RP2 forcefully handled Resident #1 without the use of draw sheets resulting in skin injury to Resident #1's arms and legs. The facility failed to ensure Resident #1's service plan was followed. RP2 was found responsible for physical abuse.",2,0,Not Substantiated,Substantiated,Physical Abuse +HB132009X,70M100,ALF,12/31/2012,Resident #1 and Resident #2 were involved in an altercation. There were no prior altercations between the two. Resident #2 does have a history of behaviors. The facility failed to address Resident #1_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB132645,70M100,ALF,3/14/2013,Resident #1 had missing narcotic medications from his/her room. Reported Perpetrator 2 (RP2) was caught entering Resident #1's room without permission. RP2 admitted to law enforcement to taking pills. RP2 was found responsible for the theft of Resident #1's medication which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB146449,70M100,ALF,3/21/2014,"Resident #1 reported missing approximately 74 narcotic pills from her/his room. Facility reported potential theft and investigation identified RP2 as a suspect. RP2 confessed to taking the narcotics and was arrested. The facility failed to ensure a safe environement and is a violation of Oregon Administrative Rules. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB147157,70M100,ALF,5/21/2014,"Resident #1 has a medical condition resulting in chronic pain that was managed by pain medications. The facility failed to provide a safe medication administration system and coordinate health care services in a timely manner resulting unreasonable discomfort from missing two days of pain medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB147417,70M100,ALF,6/16/2014,"Resident #1 had two narcotic prescriptions for pain, one was scheduled and the other as needed. The order and Medication Administration Record provided the same description of how and when to administer both medications. There were no specific parameters on the as needed order and the facility did not follow up with the physician for clarification. As a result, the medications ran out and Resident #1 missed 4 scheduled doses. The facility failed to provide a safe medication administration system resulting in unreasonable discomfort for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB149498,70M100,ALF,12/8/2014,Resident #1 received the wrong PRN pain medication that was discovered when the resident requested the return of a prescription bottle the facility was holding for her/him. There was no negative outcome as a result of the error and is a violation of Oregon Administrative Rules.,2,,,, +HB149410,70M100,ALF,12/1/2014,"Resident #1 had a history of aggressive and agitated behavior. Resident #1 had jabbed Resident #2 with a letter opener. The facility failed ot adequately care plan and monitor Resident #1's behavior resulting in harm to Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB151842,70M100,ALF,7/7/2015,"The facility failed to ensure a safe environment resulting in the loss of jewelry from Resident #1's room and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +GP105822,70M101,ALF,12/9/2010,RP2 inappropriately injected Resident #1 with another resident's medication resulting in the potential for serious harm.,3,0,Not Substantiated,Substantiated,Neglect +GP118230,70M101,ALF,10/16/2011,RP2 gave Resident #1's evening medications prior to looking at the resident's MAR resulting in the resident receiving double the dose of medication than prescribed. The facility failed to ensure a safe medication administration record resulting in the potential for harm.,2,0,,, +GP118224,70M101,ALF,10/13/2011,The facility failed to ensure an accurate medication administration record resulting in Resident #1 receiving wrong dose of medication.,2,0,,, +GP129351,70M101,ALF,2/25/2012,"Resident #1 was injured, resulting in pain and bruising, when RP2 used too much force to get his/her shoe on. The facility failed to protect Resident #1_x001A_s resident rights. The failure is a violation of Oregon Administrative Rules.",1,0,,, +GP129091,70M101,ALF,1/30/2012,Reported Perpetrator 2 (RP2) was an employee of the facility and provided care for Resident #1. RP2 accepted money from Resident #1 on several occasions. RP2 was found responsible for financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +GP145651,70M101,ALF,12/28/2013,Resident #1 reported that his/her debit card had two strange transactions. Resident #1 had given his/her debit card and pin number to Reported Perpetrator 2 (RP2) to buy him/her groceries. RP2 stated that he/she accidentally used Resident #1's debit card to withdraw cash instead of his/her own card. RP2 claims he/she took receipts and cash back to Resident #1. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL116457,70M104,ALF,12/25/2010,"A Facility staff member who was known by management and his/her peers to be ""rough"" in language and demeanor towards residents of the Facility was observed to be roughly handling and resident and barking orders at the resident. The Facility let the staff member go as a result of the incident.",2,0,,, +DA118411,70M201,ALF,10/27/2011,Resident #1 required two-person transfer. RP2 unsuccessfully attempted to transfer Resident #1 on her/his own. A few hours later Resident #1 complained of pain and was transported to the hospital for treatment of a fractured hip. The facility failed to ensure Resident #1's service plan was followed resulting in harm. RP2 was apportioned abuse.,3,0,Not Substantiated,Substantiated,Neglect +DA128849,70M201,ALF,11/19/2011,"Resident #1 had a treatment order to put clotrimazole cream ""topically to abdominal folds twice daily as needed."" Resident #1 was discovered with skin breakdown on abdominal folds. Medication Administration record showed no treatment was applied for the month of November 2011. The facility failed to administer treatment as ordered resulting in medical condition worsening. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +DA129033,70M201,ALF,1/7/2012,Resident #1 and Resident #2 had a verbal confrontation resulting in Resident #1 hitting Resident #2 on the back. Resident #1 had a history of using her/his electric scooter to antagonize residents. Resident #1's scooter speed was reduced and eventually removed resulting in Resident #1 having fewer behaviors.,0,0,,,Neglect +DA129319,70M201,ALF,12/11/2011,The facility and Resident #1's family member agreed to contact the family with any emergency and/or important information regarding Resident #1. Resident #1 refused transport to three medical appointments in one month and the facility did not contact the resident's family member. The failed to follow Resident #1's service plan resulting in poor continuity of care. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA120128,70M201,ALF,4/23/2012,"Resident #1 had a known diagnosis of asthma and experienced dizziness and shortness of breath. The facility failed to respond to Resident #1's symptoms and failed to appropriately care plan to address her/his condition resulting in transportation to the hospital for treatment. The facility also failed to follow physician's orders or install a nebulizer in the resident's room. The facility failed to provide Resident #1 with room trays when she/he was feeling ill per her/his service plan. The facility failed to plan and provide appropriate care to Resident #1 resulting in medical condition worsening. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +DA120798,70M201,ALF,8/8/2012,Resident #1 requested bath and personal hygiene assistance from care staff of the same gender. The facility failed to address Resident #1's preference and continued to attempt to use care staff of the opposite gender. Resident #1 refused assistance when care staff of the opposite gender tried to assist. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA121234,70M201,ALF,9/20/2012,Resident #1 requested and received a physician's order for a power scooter. The facility denied the request and determined that Resident 1#'s evaluation by RP2 showed the resident was unable to safely navigate a motor scooter. Facility also stated Medicaire denied the request. The facility failed to show appropriate documentation supporting findings and avocating for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +DA121588,70M201,ALF,10/8/2012,"Resident #1 entered the facility on May 2, 2012, with no known cognitive or behavioral issues. It became evident from 6/14/12 to 10/17/12 that Resident #1 was having behavior issues. The facility failed to care plan for behavioral interventions or provide staff instruction on redirecting and behavior issues. The facility also failed to assess Resident #1 for a change of condition. The failure is a violation of Oregon Administrative Rules.",2,0,,, +DA135523,70M201,ALF,11/26/2013,"Resident #1 had a few pieces of jewlery go missing in November 2013. These items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA147806,70M201,ALF,5/1/2014,"Resident #1 had pain medication go missing from his/her room twice. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA147807,70M201,ALF,6/19/2014,"Resident #1 had pain medication go missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA147809,70M201,ALF,6/23/2014,"Resident #1's cigarette case containing cash and credit cards went missing. These items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,200,Not Substantiated,Substantiated,Financial abuse +DA147810,70M201,ALF,7/8/2014,"Resident #1 had a bag go missing from his/her room. The bag was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV147802,70M201,ALF,7/16/2014,"Resident #1 had a bottle of medicine go missing from his/her room. The bottle was taken by an unknown individual, and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +DA134509,70M201,ALF,9/22/2013,The facility failed to provide Resident #1 with medication as prescribed. Resident #1 was prescribed pain medication as needed. The facility administered the pain medication to Resident #1 every two hours instead of giving it as needed. This failure is a violation of Oregon Administrative Rules.,2,,,, +DA146993,70M201,ALF,8/13/2014,"The facility failed to provide an adequate medication administration system. The facility ran out of Resident #1_x001A_s pain medication and he/she went without it for several days. Resident #1 expressed increased pain symptoms and was sent to the hospital for treatment associated with medication withdrawal. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +DA148456A,70M201,ALF,9/8/2014,The facility failed to administer Resident #1's insulin as prescribed. The facility ran out of Resident #1's medication and he/she did not receive his/her insulin on three separate occasions. This failure is a violation of Oregon Administrative Rules.,2,,,, +DA149471,70M201,ALF,9/29/2014,"Reported Perpetrator #2 (RP2) gave Resident #1 the wrong dose of insulin medication. Resident #1 had to be treated in the ER as a result. RP2 is responsible for neglect of care, which is considered abuse. The facility failed to provide a safe environment for Resident #1 which is a violation of Oregon Administration Rules.",3,,Not Substantiated,Substantiated,Neglect +DA159872,70M201,ALF,1/7/2014,"The facility failed to adequately follow Resident #1's care plan associated with a history of wandering. Facility staff noticed Resident #1 was missing, but did not adequately search for him/her after noticing he/she was gone. Resident #1 was missing for several hours and was later found on the ground outside the facility with an injury to his/her arm.",2,,,,Neglect +DA147970,70M201,ALF,7/23/2014,"Residents #1, #2, and #3 had cash and medication go missing from their rooms. An unknown individual was found responsible, and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Residents' property from theft and this is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DA152810,70M201,ALF,9/9/2015,The facility failed to provide a safe medication administration system. Resident #1 and Resident #2 received another residents medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +OR0001033000,70M201,ALF,11/25/2015,,1,,,Substantiated, +ES116964,70M202,ALF,5/6/2011,"Facility documentation revealed RP2 failed to administer Resident #1's medication as prescribed on May 7, 2011. RP2 administered the patch sometime during the day on May 8, 2011 and then applied another patch that same evening without removing the old patch. Witnesses reported Resident #1 experienced a negative outcome as the result of the errors. The facility failed to ensure medication was administered as prescribed. RP2 was found responsible for abuse.",2,0,Not Substantiated,Substantiated,Neglect +ES117009,70M202,ALF,5/10/2011,"For the purposes of the attached ALF Complaint Report, RP2 is referred to as RP1 and RP3 is referred to as RP2. Resident #1's Service Plan requires staff to check on her/his at 3:00 AM daily. On or about May 9, 2011, Resident #1 was found on the floor cold, bleeding from elbows and incontinent. RP2 was covering another caregiver's shift and was not oriented with the resident's service plan. The facility failed to ensure care giving staff were oriented to Resident #1's Service Plan prior to providing care resulting in minor harm to the resident. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES117905A,70M202,ALF,9/6/2011,RP2 gave Resident #1 wrong dose of medication resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +ES128872A,70M202,ALF,1/9/2012,Resident #1 reported $247 was taken from billfold in room. RP2 claimed that she/he found two unknown men in a nearby room and chased them out. The facility failed to provide a safe environment resulting in the loss of resident money. An unknown person was found responsible for abuse.,3,0,Not Substantiated,Not Substantiated,Financial abuse +ES129021,70M202,ALF,1/23/2012,"Resident #1 returned from the hospital with pain medication and a prescription. The facility failed to fill the prescription in a timely manner resulting in Resident #1 experiencing unreasonable discomfort for over 24 hours. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ES129717,70M202,ALF,4/1/2012,"The facility failed to have an accurate Medication Administration Record for Resident #1 resulting in the resident missing antibiotic medication for several days. Resident #1 continued to experience discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES129888,70M202,ALF,4/20/2012,"Resident #1 had increased weakness and required more assistance with transfers and mobility. The resident's care plan was updated, but failed to provide clear direction to staff on the need to stay with the resident during toileting. Resident #1 fell in the bathroom after being transferred by RP2. The facility failed to adequately care plan resulting in a fall. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 was not found responsible for abuse.",2,0,,,Neglect +ES118545,70M202,ALF,11/25/2011,"Resident #1 required assistance with incontinence care. Resident #1 was found on the morning of November 26, 2011 with a soiled garment that was noted to have been placed during the day on November 25, 2011. The facility failed to have clear directions regarding incontinence protocol. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +ES120009,70M202,ALF,5/6/2012,Resident #1 reported narcotic medication taken from her/his locked apartment. Investigation was unable to determine who could have taken the medications but staff have master keys to residents' rooms. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for financial exploitation and is considered abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ES120363,70M202,ALF,4/4/2012,"Resident #1 reported 5 missing rings from the facility. One of the rings were cut off by parametics, but never recovered. The facility failed to ensure a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknow individual was held responsible for financial exploitation and is considered abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +ES121396,70M202,ALF,10/22/2012,"RP2 was observed entering several residents' rooms on her/his day off. Money was reported missing shortly thereafter. Law enforcement were called and an internal investigation concluded RP2 was reponsible for the thefts. The facility failed to ensure a safe environment resulting in the loss of money from residents. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse.",0,0,Not Substantiated,Substantiated,Financial abuse +ES132101,70M202,ALF,1/9/2013,"Approximately 1,919 narcotic medications were stolen from the facility. Access was gained through an unsecured door while the two caregivers on duty were in the courtyard. Medication drawers in the medication room were not locked. Multiple residents (31) were without medications for up to 48 hours, some resulting in pain. The facility failed to provide a safe environment resulting in the loss of resident narcotic pain medications. The failure is a violation of resident rights and is considered financial abuse.",3,300,,,Financial abuse +ES132561,70M202,ALF,3/5/2013,"Resident #1 was administered Resident #2's medications. Per Resident #1's physician, Resident #1 was transported to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES132681,70M202,ALF,3/16/2013,Resident #1_x001A_s medications are administered by the facility. The facility ran out of his/her pain medication. The facility was able to obtain a refill the same day. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ES134662,70M202,ALF,10/5/2013,Resident #1 requires staff administration of her/his medication. RP2 administered an additional dose of the resident's medication. Hourly monitoring revealed no harm as a result of the medication error. The facility failed to ensure a safe medication administration and is a violation of Oregon Administrative Rules.,2,,,, +ES134352,70M202,ALF,9/6/2013,Resident #1 uses an assistive device that requires using the mechanical lift to get into the facility van. RP2 failed to ensure Resident #1's safety before starting the lift resulting in the resident falling backwards and hitting her/his head on the pavement. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care and constitutes abuse.,2,,Not Substantiated,Substantiated,Neglect +ES133984,70M202,ALF,7/30/2013,Resident #1 had orders for water pills and antibiotics. The facility failed to administer these medications as ordered resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +ES159772,70M202,ALF,12/17/2014,The facility failed to provide Resident #1 his/her medication as ordered. Resident #1 did not receive a higher dose of his/her medication as ordered for several days. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES150207,70M202,ALF,1/28/2015,The facility failed to administer Resident #1's medication as ordered. Resident #1 did not receive his/her medication for several days. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES149717,70M202,ALF,12/29/2014,"The facility failed to follow Resident #1's care plan and provide showers twice a week and assistance with incontinence. Resident #1 missed several showers and was left in wet briefs once for several hours. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES150493,70M202,ALF,3/2/2015,"Resident #1 had medication go missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +ES151244,70M202,ALF,4/10/2015,"Resident #1 had jewlery go missing from his/her room. The jewlery was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES149158,70M202,ALF,11/4/2014,The facility failed to adequately provide a safe medication administration system. Reported Perpetrator #2 place Resident #1's medications in front of him/her but failed to watch them take it. Resident #2 took Resident#1's medications by mistake. Resident #2 did not exhibit any ill effects from the medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES152040,70M202,ALF,6/27/2015,The facility failed to administer Resident #1 and Resident #2's medications as prescribed. Resident #1 was given Resident #2's medication by mistake. This failure is a violation of Oregon Administrative Rules.,1,,,, +ES151313,70M202,ALF,4/24/2015,"The facility failed to adequately plan care for Resident #1. Resident #2 missed doses of medication, missed several showers, and did not have his/her catheter bag in a timely manner. This failure is a violation of Oregon Administrative Rules.",2,,,, +ES148891,70M202,ALF,10/13/2014,The facility failed to ensure Resident #1 took his/her medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES152491A,70M202,ALF,8/14/2015,"The facility failed to provide a safe medication administration system and get Resident #1's medications filled timely. Resident #1 missed a dose of anxiety medication and experienced increased anxiety symptoms as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ES152713,70M202,ALF,9/4/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES152734,70M202,ALF,9/5/2015,"The facility failed to assist Resident #1 with getting dressed, and bring him/her to the dining room. Resident #1 had to wait several hours for assistance. This failure is a violation of Oregon Administrative Rules.",2,,,, +ES153423,70M202,ALF,10/27/2015,The facility failed to adequately provide a safe medication administration system. Resident #1 missed doses of medication as a result. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES154095,70M202,ALF,12/23/2015,The facility failed to adequately maintain a safe medication administration system. Resident #1 was given a different resident's medication by mistake. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES153663,70M202,ALF,11/17/2015,The facility failed to adequately provide a safe medication administration system. Resident #1 missed one dose of medication due to the facility filling his/her prescription late. This failure is a violation of Oregon Administrative Rules.,2,200,,, +ES164497,70M202,ALF,1/28/2016,"Resident #1 had items go missing from his/her room. The items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +OR0000999101,70M202,ALF,9/2/2015,,0,,,Substantiated, +CO11080,70M203,ALF,5/6/2011,"The Facility failed to ensure residents were monitored and evaluated according to their needs, failed to ensure significant changes of condition were referred to the RN as well as failed to provide an RN assessment. Resident #1, Resident #3, and Resident #5 suffered severe weight loss, and Resident #6 suffered unrelieved pain. The Facility_x001A_s failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,1200,,,Neglect +AS116648,70M203,ALF,3/22/2011,"Medications for Resident #1 and Resident #2 were discovered missing from the medication room; however neither resident missed any doses and the facility replaced the medications. During the course of the investigation, it was inconclusive as to who took the medications, therefore an unknown individual.",2,0,Not Substantiated,Substantiated,Financial abuse +AS129126,70M203,ALF,1/26/2012,"During a routine medication audit, it was discovered that a PRN narcotic medication was administered to Resident #1 for shoulder pain. Resident #1 denied shoulder pain and denied taking the PRN narcotic medication. Reported Perpetrator 2 (RP2) was the signer on the documentation and later admitted to stealing the narcotic medication. RP2 is responsible for the theft of medications. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +AS129462,70M203,ALF,3/8/2012,"The facility failed to have medication available for Resident #1 resulting in 3 days without medication. Resident #1 was alert, oriented and able to share concerns; and he/she did not have any ill effects from the missed medications. The facilities failure is a violation of Oregon Administrative Rules.",2,0,,,Neglect +AS121972,70M203,ALF,12/23/2012,"Resident #1 was administered another residents medication in error. The error was discovered, protocol was followed, and he/she was sent to the hospital for evaluation. Resident #1 suffered no medical negative effects. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.",2,0,,, +AS132702,70M203,ALF,3/19/2013,"It was reported an unknown person took pain medications from Resident #1's room. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the medications, which is considered theft and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +AS133477,70M203,ALF,6/11/2013,"Reported Perpetrator 2 (RP2) had several of Resident #1's identification cards, including a driver's license and insurance cards in RP2's wallet for a couple of weeks until they were found by a facility staff. RP2 stated he/she accidentally washed the cards along with Resident #1's cell phone in the laundry and forgot to return the cards. The cards were not used by RP2. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +AS146813,70M203,ALF,4/16/2014,"Resident #1 had several items go missing from their room. These items were taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +AS132348,70M203,ALF,2/4/2013,"Resident #1 had money go missing out of his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +AS132778,70M203,ALF,3/24/2013,Reported Perpetrator 2 entered Resident #1's room and refused to leave. The facility failed to ensure Resident #1 was treated with dignity and respect. This was a violation of Oregon Administrative Rules.,2,,,, +AS132604,70M203,ALF,3/11/2013,"Resident #1 had medication go missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +AS145881,70M203,ALF,1/6/2014,"Resident #1 was given another resident's medication by mistake, which caused Resident #1 to be sent to a hospital for evaluation. Reported perpetrator 2 was found to be responsible for giving Resident #1 the wrong medication, which is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +AS148929,70M203,ALF,10/14/2014,"The facility failed to ensure care staff followed Resident #1's care plan. Resident #1 required two hour bed checks due to his/her risk of falls. The bed checks were not completed and Resident #1 fell suffering a skin tear. This failure is a is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AS149609,70M203,ALF,12/16/2014,"Resident #1 had money go missing from their room. An unknown individual took the money and is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BH116504,70M204,ALF,12/5/2010,"The Facility failed to properly assess a resident who returned from the hospital with a significant change in condition resulting in the resident not receiving adequate supervision. The resident suffered a fall with significant injury and was not checked on until morning, where he/she was found to have suffered considerable bleeding.",3,300,,,Neglect +BH116962,70M204,ALF,5/3/2011,"The facility failed to follow Resident #1's care plan to prepare him/her for a new situation for Witness 2 to provide care to his/her roommate, Resident #2. Resident #1 became physical towards Witness 2 on his/her first evening of providing care. Witness 2 activated the call light for staff assistance; however staff did not answer the call light timely.",2,0,,, +BH118279,70M204,ALF,10/19/2011,Resident #3 reported cash missing on 3 separate occasions. The facility set up hidden cameras with permission. The cameras showed RP2 taking money from Resident #1_x001A_s purse. RP2 was responsible for taking the money. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BH159814,70M204,ALF,1/2/2015,"The facility failed to ensure a safe environment resulting in a resident to resident altercation that resulted in minor harm. The failure is a violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +MV121736,70M205,ALF,11/25/2012,Resident #1 was care planned for total assist with transfers and used a call light to request assistance. RP2 took Resident #1's call light from her/him resulting in Resident #1 becoming very upset and leaving the resident vulnerable to potential harm. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for involuntary seclusion and constitutes abuse.,2,0,Not Substantiated,Substantiated,Involuntary Seclusion +WB133139,70M205,ALF,5/3/2013,"Reported Perpetrator 2 (RP2) changed Resident #1's incontinence product against Resident #1's will. RP2 stated he/she held on to Resident #'1s heel because Resident #1 was kicking at RP2. The facility failed to protect Resident #1 from rough treatment. The failure is a violation of Oregon Administrative Rules. RP2 used force with Resident #1, which constitutes physical abuse.",2,,Not Substantiated,Substantiated,Physical Abuse +WB159978,70M205,ALF,1/16/2015,Resident #1 was administered another residents' medications in error. The facility failed to ensure a safe medication administration system and violated Oregon Administrative Rules.,2,,,, +WB151132,70M205,ALF,4/22/2015,"Resident #1 reported money missing from his/her room, approximately $180. The investigation revealed an unknown individual is responsible for theft of his/her money and constitutes financial exploitation. The facility failed to provide a safe environment and violates Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Financial abuse +BH116971A,70M206,ALF,4/11/2011,"The facility failed to adequately assess, intervene and implement interventions when Resident #1 experienced a significant change of condition after a fall with increased care needs from April 12 _x001A_ 14, 2011. On April 14, 2011, Resident #1 complained of chest pain, was transported to the hospital and diagnosed with a blood clot. The Facility_x001A_s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BH117815,70M206,ALF,8/10/2010,Resident #1's coin purse was discovered missing from his/her room. A conclusion of the investigation determined that an unknown individual was responsible for taking his/her property.,2,0,Not Substantiated,Substantiated,Financial abuse +BH128889,70M206,ALF,1/5/2012,Resident #1 had physician's orders to self medicate and had narcotic medication in his/her room. Thirteen tabs of a narcotic medication were stolen from his/her room. The theft of medications was a result of an unknown individuals action.,2,0,Not Substantiated,Substantiated,Financial abuse +BH128822,70M206,ALF,12/22/2011,"Resident #1 kept his/her jewelry in the locked drawer and was always aware of where he/she kept the key. On 12/22/11, Resident #1 discovered her jewelry missing (valued at approximately $7000) and replaced with costume jewelry. An unknown individual is responsible for the theft of Resident #1_x001A_s jewelry. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",3,0,Not Substantiated,Substantiated,Financial abuse +BH120810,70M206,ALF,7/2/2012,"Resident #1's prescribed narcotic medication dosage was incorrectly administered to him/her causing over-sedation. The facility failed to have a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BH121429,70M206,ALF,10/16/2012,"Resident #1 had left some of his/her money in an envelope in a locked drawer at the reception desk on 10/16/2012. On 10/22/12, a portion of the money was discovered missing from the envelope. An unknown individual is responsible for the loss of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +BH121673,70M206,ALF,11/17/2012,"The facility failed to care plan appropriately and implement interventions regarding Resident #3_x001A_s behaviors. Resident #1 and Resident #2 were affected by Resident #3_x001A_s behaviors. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse and constitute abuse.",3,2500,,,Neglect +BH121723,70M206,ALF,11/22/2012,Resident #1 discovered approximately $3700 missing from his/her apartment. An unknown person is responsible for the theft of money. The facility failed to provide a safe environment resulting in the loss of Resident #1's money.,3,0,Not Substantiated,Substantiated,Financial abuse +BH121724,70M206,ALF,11/16/2012,Resident #1 was administered medications prescribed for Resident #2. The error was timely discovered and reported. Resident #1 did not suffer ill effects. The facility failed to provide a safe medication administration system and the failure is a violation of Oregon Administrative Rules.,2,0,,, +BH134638,70M206,ALF,1/21/2013,Resident #1 reported pain medications missing from his/her room. The theft of medications resulted from the actions of an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BH148086,70M206,ALF,7/24/2014,"Resident #1 had a physician's order for medication changes on July 24, 2014. The changes were not implemented until August 6, 2014. Resident #1 experienced no negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",1,,,, +BH149574,70M206,ALF,10/6/2014,Resident #1 was not administered his/her medication according to physician's orders. Resident #1 did not experience any negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH147270,70M206,ALF,12/20/2013,Resident #1 reported some of his/her narcotic medication had been replaced with over-the-counter medication. He/she also reported $60.00 missing from his/her locked drawer. An unknown individual was found responsible for the loss of Resident #1's medication and money which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BH153351,70M206,ALF,7/15/2015,"Resident #1 requested PRN pain medication around 1:00 a.m. due to being in pain. He/she was told by the only staff on duty that he/she had to wait until the morning shift arrived due to not knowing what to do since the medication was flagged in the system. The facility failed to administer medication as ordered, train staff appropriately and provide an adequate number of staff at night to meet the needs of the residents. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BH164773,70M206,ALF,5/22/2015,Resident #1 had a camera in his/her room. Reported Perpetrator 2 (RP2) was viewed on video taking money from Resident #1. RP2 was found to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RD117398,70M207,ALF,6/20/2011,"Reported Perpetrator 2 (RP2) spoke disrespectfully to Resident #1, Resident #2 and Resident #3 on different occasions resulting in Resident #2 having fear to use the call light and went to the bathroom on his/her own instead of asking for help like usual, and Resident #1 was re-directed and comforted by another staff person.",2,0,,, +BO118240,70M207,ALF,9/1/2011,Resident #1 had $200 stolen out of his/her room. Reported Perpetrator 2 confessed to stealing his/her money.,2,0,Not Substantiated,Substantiated,Financial abuse +CO12065,70M207,ALF,3/9/2012,"The facility failed to monitor and evaluate Resident #2_x001A_s changes in needs, document the changes, refer significant changes to the facility RN, conduct an RN assessment and update service plans accordingly. Resident #2 experienced significant changes in condition due to the death of his/her spouse, hospitalization after receiving a psychoactive medication, altered emotional status and a severe weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +CO12090,70M207,ALF,6/12/2012,"The facility failed to ensure Resident #9 was monitored or evaluated, and interventions developed when he/she experienced a significant change of condition. The facility failed to provide a Registered Nurse assessment. Resident #9 experienced a severe weight loss. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BO145691,70M207,ALF,12/28/2013,"Reported Perpetrator 2 greeted Resident #1 by saying ""hey beautiful"" in passing. Resident #1 felt this was not a respectful way to greet residents. The facility failed to ensure Resident #1 was treated with dignity and respect. This failure is a violation of Oregon Administrative Rules.",2,,,, +BO147949,70M207,ALF,6/3/2014,The facility failed to ensure facility staff visually observed Resident #1 take his/her medication. This failure violates Oregon Administrative Rules.,2,,,, +RD149353,70M207,ALF,10/28/2014,Reported Perpetrator #2 (RP2) called Resident #1 a derogatory name on numerous occasions and is responsible for verbal abuse. The facility failed to protect Resident #1 from verbal abuse. This failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +RD149679,70M207,ALF,12/14/2014,The facility failed to administer Resident #1's sleep and appetite stimulation medication. Resident #1 missed several days of medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +RD151671,70M207,ALF,6/8/2015,"Resident #1's sleep aid medication went missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BO152067,70M207,ALF,7/1/2015,"The facility failed to adequately assess Resident #2 and implement interventions to reduce his/her fall risk. Resident #2 fell several times and developed bruising as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +CO11064,70M208,ALF,3/17/2011,"The facility failed to evaluate and monitor, coordinate care with home health and ensure medication orders were carried out as prescribed resulting in unrelieved pain to Resident 2. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MM116360,70M208,ALF,2/11/2011,The Facility failed to provide a safe medication system resulting in harm to Resident #1. The resident experienced severe diarrhea as well as vomiting when he/she was given a medication in which he/she was not prescribed.,3,400,,,Neglect +MM116805A,70M208,ALF,4/14/2011,The facility failed to ensure Resident #1 was treated with dignity and respect. The failure is a violation of resident rights.,2,0,,, +MM116805B,70M208,ALF,4/14/2011,"The facility failed to provide a safe medication resulting in Resident #1 not receiving medications as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM117029,70M208,ALF,4/14/2011,The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving her/his medication as ordered for approximately two weeks. There was no harm as a result of the error. The failure is a violation of OARs.,2,0,,, +MM117130A,70M208,ALF,5/14/2011,The facility failed to provide a safe environment resulting in Resident #1 being administered the wrong medication. Resident #1 was being administered Abien in lieu of Clonazapam. The failure is a violation of OARs.,2,600,,, +MM117130B,70M208,ALF,5/14/2011,The facility failed to provide a safe medication administration system resulting in the potential for harm. Medication Administration Records were transcribed incorrectly resulting in multiple residents not being administered their medications as ordered. The failure is a violation of resident rights and is a violation of OARs.,2,0,,, +MM118661,70M208,ALF,11/29/2011,"Resident #1 had a history of aggressive behavior and was known that she/he did not get along with Resident #2. On two separate occasions Resident #1 and Resident #2 were involved in altercations and was not addressed on the residents' care plans. The facility failed to address behaviors resulting in altercations between Resident #1 and Resident #2. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM120422,70M208,ALF,6/25/2012,"Resident #1 had prescription for regularly scheduled narcotic medication for pain. The facility failed to timely reorder Resident #1's medication resulting in unecessary pain from several missed doses. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MM120328,70M208,ALF,6/14/2012,"Resident #1 had a history of verbally inappropriate behavior towards staff and residents including Resident #2. Care plans instructed staff to keep Resident #1 away from Resident #2 and monitor in the dining room. Resident #1 was verbally abusive towards Resident #2 and her/his family. The failure is a violation of resident rights, is considered neglect of care resulting in verbal abuse.",2,0,,,Verbal/Mental abuse +MM120777,70M208,ALF,8/5/2012,"Resident #1 had a order to receive a narcotic pain patch every 72 hours. It was discovered that Resident #1 had not received the pain patch after she/he was observed to be in pain. The facility failed to provide a safe medication administration system resulting in Resident #1 experiencing unrelieved pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however one was not issued due to the length of time between the investigation and processing by the Department.",3,,,,Neglect +MM135295,70M208,ALF,11/8/2013,"Facility staff issued medications to Resident #1. Resident #1 was hiding his/her medications, not taking them, and his/her medical conditioned worsened. The facility failed to watch and make sure Resident #1 took his/her medications. This failure is considered neglect of care, which constitutes abuse, and violates Oregon Administrative Rules.",3,300,,,Neglect +MM121579,70M208,ALF,8/15/2012,"Resident #2 had a history of aggressive behaviors. On or about August 15, 2012, Resident #2 hit Resident #1 in the face when approached. The facility failed to adequately care plan for Resident #1's aggressive behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation and when it was received by the Department.",2,,,,Neglect +MM121580,70M208,ALF,11/7/2012,"Resident #2 had a history of aggressive behavior. On or about November 7, 2012, Resident #1 and Resident #2 engaged in a physical altercation. The facility failed to appropriately monitor and care plan around Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation and when it was received by the Department.",2,,,,Neglect +MM121581,70M208,ALF,8/22/2012,"Resident #2 had a history of aggressive behavior and care planned to remove other residents from surrounding area if agitated. On or about August 22, 2012, Resident #2 was cursing and yelling at Resident #1 resulting in an altercation. The facility failed to follow Resident #2's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation and when it was received by the Department.",2,,,,Neglect +MM121582,70M208,ALF,8/24/2012,"Resident #2 had a history of agitation and care planned with interventions. On or about August 224, 2014, Resident #1 and Resident #2 engaged in a physical altercation. Facility incident indicated that the residents would be separated, eat in separate areas and kept under continuous supervision. Neither residents' care plan address these interventions. The facility failed appropriately monitor behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation and when it was received by the Department.",2,,,,Neglect +MM147742,70M208,ALF,7/8/2014,"Resident #1 was transported to the hospital for treatment after RP2 administered a medication that was on hold. Investigation revealed RP2 was a new employee and being trained at the time of the incident. The facility failed to ensure a safe medication administration system resulting in harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,250,,,Neglect +MM150704,70M208,ALF,3/7/2015,Resident #1 reported missing money from her/his purse and RP2 was suspected. Investigation was unable to confirm who took the money and an unknown person was found responsible. Theft of money is considered financial exploitation and constitutes abuse. The facility failed to ensure a safe environment which is a violation of Oregon Administrative Rules.,2,,Inconclusive,Substantiated,Financial abuse +MM148274,70M208,ALF,8/14/2014,"Resident #1 reported missing two ruby rings. Resident #1's room was searched without success. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for the theft, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +MM151690,70M208,ALF,6/13/2015,"Resident #1 was care planned to self-administer her/his own medication and regularly took an over the counter medication to address constipation. On or about June 13, 2015, Resident #1 experienced constipation that required transportation to the hospital for treatment. Investigation revealed a staff member took away Resident #1's over the counter constipation medication a few days prior. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM148640,70M208,ALF,9/12/2014,The facility failed to ensure a safe environment resulting in the potential for harm. RP2 was a new medication aide who attempted to give Resident #1 another resident's medication. W4's name was used on the MAR when RP2 administered residents' medication. RP2 provided Resident #2 with another resident's medication. There was no negative outcome as a result of the medication error. The failures are violations of Oregon Administrative Rules.,2,,,, +MS118014,70M210,ALF,9/10/2011,"On 9/20/11, Resident #1 and Resident #2 reported money missing from their respective wallets. On 9/21/11, Resident #3 reported missing medications. An unknown individual was responsible for the loss of resident property.",2,0,Not Substantiated,Substantiated,Financial abuse +MS118372,70M210,ALF,11/5/2011,Reported Perpetrator 2 improperly transferred Resident #1 causing him/her pain.,2,0,Not Substantiated,Substantiated,Physical Abuse +MS120175,70M210,ALF,5/30/2012,Resident #1's $100 went missing from his/her wallet that was located in his/her room; and the money was not found upon a room search. An unknown individual is responsible for Resident #1's loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +MS133228B,70M210,ALF,5/10/2013,"A complaint was received that the facility failed to protect Resident #1 from inappropriate verbal interactions. Upon investigation, it was determined that Reported Perpetrator 2 (RP2) did enter Resident #1_x001A_s room speaking loudly and addressed Resident #1_x001A_s frequent use of his/her call light. The facility failed to assure Resident #1_x001A_s rights. The failure is a violation of Oregon Administrative Rules.",2,,,, +MF133954,70M210,ALF,7/29/2013,Reported Perpetrator 2 (RP2) administered Resident #1's morning medications. There was an extra pill and Resident #1 caught the error. Resident #1 did not take the medication and RP2 took the extra pill and destroyed it. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS148196,70M210,ALF,8/19/2014,Resident #1 reported several gift cards missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MS148230,70M210,ALF,8/21/2014,Resident #1 was sent to the hospital and while there a discrepancy was found with his/her MAR. A medication showed it had been dispensed but had not. The facility explained the discrepancy by stating they pre-popped the dose in anticipation of Resident #1 requesting it. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS159963,70M210,ALF,1/15/2015,"Resident #1 was administered his/her narcotic medication by Reported Perpetrator 2 (RP2) at 0600 hours and then again at 0800 hours in error. Resident #1 experienced shortness of breath and redness as a result. RP2 was found responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system. + +The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +MF150229,70M210,ALF,2/12/2015,"Resident #1 was not administered his/her medications due to them being out of stock. Resident #1 had been in pain due to not receiving his/her pain medications. The facility failed to administer Resident #1's medications according to physician's orders. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS150622,70M210,ALF,3/14/2015,"Reported Perpetrator #2 (RP2) failed to provide adequate care for Residents #1 - #3 as indicated in their care plans. Resident #1 was found on the floor of his/her room with an arm injury and was completely soaked in his/her own urine. Resident #2 and Resident #3 were also found completely soaked in their own urine. RP2 is responsible for neglect of care, which constitutes abuse. The facility failed to provide a safe homelike environment which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +MS151470A,70M210,ALF,6/5/2015,"Resident #1 had a history of closing the kitchen doors due to the noise. Resident #1 went to shut the kitchen doors for the third or fourth time. Reported Perpetrator 2 (RP2) became upset and blocked the doorway with his/her foot and would not let Resident #1 close the kitchen doors. RP2 hit Resident #1 in the chest. RP2 was found responsible for physical abuse. + +The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Physical Abuse +MS151470B,70M210,ALF,6/5/2015,Resident #1 and Reported Perpetrator 2 (RP2) were involved in a verbal altercation regarding closing the kitchen doors. RP2 was heard yelling at Resident #1 in a hostile threatening manner while using inappropriate language. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MF153204,70M210,ALF,10/20/2015,Reported Perpetrator 2 (RP2) told Resident #1 that RP2 was tired of transferring him/her because it makes RP2 smell like Resident #1_x001A_s body odor. Resident #1 was offended by RP2_x001A_s statement. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB105836,70M211,ALF,12/9/2010,"The locking cabinet provided by the facility was out of reach for Resident #1, so he/she placed gifts for his/her family on a shelf in her room where reachable on 12/5/10. On 12/10/10, the items were missing. Theft occurred by an unknown individual.",2,0,Not Substantiated,Substantiated,Financial abuse +HB120285,70M211,ALF,4/25/2012,Resident #1's physician prescribed a medication on 4/25/12; however it was not appropriately followed up on and was ordered on 5/9/12. The facility failed to have medication available to follow physician's orders. The failure is a violation of Oregon Administrative Rules.,2,0,,, +HB132314,70M211,ALF,2/4/2013,"On 1/31/13 at 10pm, Witness 1 and Witness 3 counted and documented the presence of the narcotics to be discarded. At the subsequent shift changes, none of the staff count these medications as per policy. On 2/24/13 at 5am, Witness 1 and Witness 2 counted the narcotics to be discarded and discovered that 38 narcotic pills were missing. The facility failed to provide a safe medication system and staff failed to follow facility policy. The failures are a violation of Oregon Administrative Rules. An unknown individual is responsible for the theft of narcotic medications.",2,0,Not Substantiated,Substantiated,Financial abuse +HB132797,70M211,ALF,3/29/2013,"Resident #1's prescription medications were discontinued in early March. In late March, it was discovered some of the medications were missing during a medication count. It was unknown who took the medications. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HB133833,70M211,ALF,7/12/2013,Reported Perpetrator 2 (RP2) gave Resident #1 an antihistamine medication to help Resident #1 sleep. Resident #1 did not have a physician's order for the medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO14194,70M211,ALF,8/27/2014,"The facility failed to ensure an RN assessed and documented findings for Resident #4 who experienced a significant change of condition. Resident #4 experienced infection and pain from a worsening pressure ulcer. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB149108B,70M211,ALF,11/3/2014,"The facility failed to care plan and implement interventions regarding Resident #1's behaviors towards Resident #2. Resident #1 stated profanities towards Resident #2 and was physically aggressive by ramming him/her with his/her power scooter. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB151502,70M211,ALF,6/8/2015,Resident #1 and Resident #2 had an exchange of verbal insults but no injury. There was prior history of behaviors between these two residents. The facility failed to care plan appropriately with interventions to provide a safe environment for Resident #1 and Resident #2. The failures are a violation of resident rights and violates Oregon Administrative Rules.,2,,,, +RD152997,70M212,ALF,9/5/2015,Resident #1 discovered three twenty dollar bills missing. An unknown person is responsible for the theft of his/her money. The facility failed to ensure a safe environment which violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BH116622A,70M213,ALF,3/21/2011,The facility failed to complete Resident #1_x001A_s Move-In and 30-Day Assessment properly.,2,0,,, +BH116622B,70M213,ALF,3/21/2011,"Resident #1_x001A_s Service Plan dated 2/2011 indicated the facility was responsible for administering his/her medications. Resident #1 did not receive his/her medications as prescribed, resulting in bowel side effects.",2,0,,,Neglect +BH132922,70M213,ALF,4/10/2013,"Resident #1 was discovered on the floor of his/her bathroom around 7:00 a.m. The fall was unwitnessed. He/she sustained a contusion on his/her face, a head injury and a facial hematoma. Resident #1 was transported to the hospital. Reported Perpetrator 2 (RP2) and Reported Perpetrator 3 (RP3) failed to follow Resident #1's service plan regarding 2 hours checks, 2 hour toileting and the placement of his/her wheelchair. RP2 and RP3 were found responsible for neglect of care which constitutes abuse. The facility failed to follow Resident #1's service plan regarding 2 hours checks, 2 hour toileting and the placement of his/her wheelchair. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,Substantiated,Substantiated,Neglect +OR0000985902,70M213,ALF,7/29/2015,,0,,,Substantiated, +BH104622A,70M213,ALF,6/22/2010,Resident #1 was not administered his/her medications as prescribed. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BH104622B,70M213,ALF,6/22/2010,"Resident #1's care plan stated he/she was independent in nutrition and health maintenance. Resident #1 experienced weight loss, had difficulty swallowing and refused meals. The care plan was not updated nor were interventions put into place. The facility failed to properly plan care for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC118139,70M216,ALF,8/31/2011,RP2 administered Resident #1 medication that RP3 set up. Resident #1 was administered the wrong medications and was put on alert charting with no observable negative outcome. The facility failed to ensure a safe medication administration system resulting in the potential for harm.,2,0,,, +BC118797,70M216,ALF,12/19/2011,Resident #1 received three medications that were prescribed to another resident. He/she was placed on alert charting for several days. Resident #1 did not show any signs or symptoms of adverse effects from receiving the wrong medications.,2,0,,, +BC128864,70M216,ALF,1/2/2012,Resident #1 received seven medications that were prescribed to another resident. He/she was placed on alert charting for several days. Resident #1 did not show any signs or symptoms of adverse effects from receiving the wrong medications.,2,0,,, +BC120413,70M216,ALF,6/23/2012,"Resident #1 was given the incorrect dose of his/her medication five times on June 23, 2012. He/she was given 1 ml instead of .5 ml. Resident #1 did not have any negative side effects from the error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC121236,70M216,ALF,9/12/2012,"On May 12, 2012 and May 18, 2012, narcotic medication was delivered to the facility for RV1 and RV2, respectively. The medications were logged into facility records as received. On May 19, 2012, a routine medication audit revealed Resident #1 was missing 18 tablets of his/her prescribed narcotic medication and Resident #2 was missing 20 tablets of his/her prescribed narcotic medication. Facility copies of the pharmacy packing slips were unaccounted for in the facility records. The facility failed to provide a safe environment. The failure is a violation of Oregon administrative Rules.",2,0,Not Substantiated,Substantiated, +BC121428,70M216,ALF,10/25/2012,Resident #1 was given the wrong medication. The only reported side effect was that Resident #1 did not feel well for several days. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC132408,70M216,ALF,2/10/2013,Reported Perpetrator 2 (RP2) administered another resident_x001A_s medications to Resident #1. RP2 realized immediately and had Resident #1 spit the medications out. Resident #1 ingested three supplements that did not have any adverse effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC132777,70M216,ALF,3/21/2013,Resident #1 requested a PRN medication and he/she was given a discontinued medication. Resident #1 had no adverse side effects from the medication error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BC133483,70M216,ALF,6/4/2013,Reported Perpetrator 2 (RP2) incorrectly administered Resident #1's pain medication when he/she gave the medication to Resident #1 two hours early on four separate occasions. No adverse effects were reported. The failure to administer medication as ordered is a failure of Oregon Administrative Rules.,2,,,, +BC133486,70M216,ALF,6/9/2013,Resident #1 was given another residents medications. Resident #2 received a double dose of his/her narcotic pain medication. There were no negative effects to Resident #1 or Resident #2. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC134097,70M216,ALF,8/9/2013,Resident #1 was given an incorrect amount of his/her prescribed medication. Resident #1 was placed on alert charting and showed no adverse effects from the medication error. The facility failed to administer Resident #1_x001A_s medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC133982,70M216,ALF,7/31/2013,Resident #1 was given a double dose of his/her newly prescribed medication. Resident #1 was placed on alert charting and showed no adverse effects from the medication error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC134273,70M216,ALF,8/29/2013,"Resident #1 was given another resident_x001A_s medications and was then placed on alert charting. Resident #1 was found semi-conscious later the same morning and was sent to the hospital. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BC135340,70M216,ALF,12/8/2013,Resident #1 was given three tablets of medication instead of the prescribed two. Resident #1 was placed on alert charting and monitored. Resident #1 did not experience a negative outcome. The facility failed to administer Resident #1_x001A_s medications as prescribed. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC147012,70M216,ALF,5/6/2014,Resident #1 requested his/her PRN medication. Resident #1 was administered the medication. It was found that Resident #1 had already received his/her PRN medication. Resident #1 had no adverse effects due to the extra dosage. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC147869,70M216,ALF,7/19/2014,Resident #1 was administered a medication that had been discontinued by his/her physician. Resident #1 did not experience any negative effects. The facility failed to maintain a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC147929,70M216,ALF,7/26/2014,Resident #1 was administered his/her as needed pain medication instead of the regularly scheduled medication. It was the same medication except a smaller dose. Resident #1 experienced no negative effects. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC148023,70M216,ALF,8/4/2014,Resident #1 was administered a medication that had been discontinued by his/her physician. Resident #1 did not experience any negative affects due to the error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC148009,70M216,ALF,8/1/2014,Resident #1 was administered the same medication twice on the same day. He/she did not experience any adverse effects from receiving the additional dose of pain medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,250,,, +BC148602,70M216,ALF,9/14/2014,Resident #1 was prescribed medication to be administered once per day. Resident #1 did not receive one of his/her medications on 9/14/14. The facility failed to administer Resident #1's medication as ordered. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC148984,70M216,ALF,10/16/2014,Resident #1 was administered 20 milligrams of medication instead of 15 milligrams. Resident #1 had no adverse effects. The facility failed to administer Resident #1's medication as prescribed by his/her physician. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC149518,70M216,ALF,12/4/2014,"Resident #1 was administered medication that belonged to another resident. Resident #1 reported feeling dizziness and a headache. He/she was placed on alert charting. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +BC159914,70M216,ALF,1/11/2015,Resident #1 was given medications that belonged to another resident. There was no negative outcome to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC150406,70M216,ALF,2/23/2015,RP2 administered the wrong medications to Resident #1. Internal investigation revealed that RP2 did not follow protocol and was pulled from administering medications. There was no harm as a result of the medication error. The facility failed to ensure medications were administered as ordered and is a violation of Oregon Administrative Rules.,2,,,, +BC152006,70M216,ALF,7/7/2015,"On or about July 7, 2015 at approximately 9:00 am Reported Perpetrator #2 (RP2) administered numerous medications to Reported Victim #1 (RV1) in error. RP2 was is training when the medication error occurred. The facility notified the appropriate physician and pharamacist and monitored RV1's vitals. RV1 did not have any adverse reactions to the medication error. The facility failed to administer RV1's medications as ordered placing RV1 at risk for potential harm.",2,,,, +RD106012,70M217,ALF,12/3/2010,"Two residents who were admitted to the Facility were found to have non-traditional sleep schedules. As a result, the residents routinely missed meals. When the residents would want to eat, there were no staff to prepare meals for the residents, and no meals were set aside for when the residents would routinely seek food.",2,0,,, +RD116282,70M217,ALF,1/7/2011,"A Facility staff member administered medications to a resident that were intended for a different resident of the Facility. The staff member recognized the error immediately following the administration, even though the resident had indicated concern prior to taking the medication. The resident did not suffer any noted physical outcome as a result of the medication error, but was placed at risk for harm due to the error.",2,0,,, +RD117129,70M217,ALF,4/15/2011,A resident of the Facility received medications intended for another resident who shared the same first name. The mistake was noticed immediately and the resident received his/her appropriate medication. The resident did not suffer any negative side effects as a result of receiving another resident's medications.,1,0,,, +CO13030,70M217,ALF,3/13/2013,"A re-licensure survey completed on January 24, 2013, relevant portions of which are attached and incorporated into this notice by reference, substantiated the following: Resident #1 suffered untreated symptoms of a urinary tract infection. The facility failed to adjust a medication for Resident #1 after receipt of information from an outside provider. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RD134623,70M217,ALF,8/17/2013,"While transferring Resident #1 from the commode to his/her wheelchair, Reported Perpetrator 2 (RP2) pushed the power button on the wheelchair, hitting Resident #1's left calf. Resident #1's calf was bruised. Several days later Resident #1 had increasing pain and was transferred to the hospital to have excess fluid drained from his/her calf. Resident #1's care plan stated a slide board was to be used for transfers, which RP2 failed to do. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. RP2 is responsible for neglect, which constitutes abuse.",3,,Not Substantiated,Substantiated,Neglect +BO148983,70M217,ALF,8/28/2014,Resident #1 reported jewelry and other items missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RD149670A,70M217,ALF,11/23/2014,Resident #1 reported $157.00 missing from his/her wallet. Resident #3 reported $600.00 missing from his/her room. Resident #2 reported $26.00 missing from his/her wallet. The facility installed a security camera in Resident #1's apartment with Resident #1's permission. Reported Perpetrator 2 (RP2) was observed in Resident #1's room going through his/her purse and taking snack bags of chips from the cupboard and eating them. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RD149670B,70M217,ALF,11/23/2014,A security camera captured Reported Perpetrator 3 (PR3) drinking hard alcohol from bottles that were in Resident #1's kitchen. The camera also captured RP3 taking snack bags of chips from the cupboard and eating them while he/she was in Resident #1's room. RP3 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RD152867,70M217,ALF,8/21/2015,"Resident #1 reported $170.00 missing from his/her room. Resident #2 reported $70.00 missing from his/her room. An unknown individual was determined to be responsible for theft, which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,300,Not Substantiated,Substantiated,Financial abuse +BO152068,70M217,ALF,7/10/2015,Resident #1 was not feeling well and was laying down. Resident #1 requested wet towels and would alternate between warm and cool. Reported Perpetrator 2 (RP2) became aggravated and threw the wet towel at Resident #1. The towel hit Resident #1 in the stomach and caused him/her pain. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules.,2,,,, +RD153584,70M217,ALF,11/12/2015,"Resident #1 reported a bottle of perfume missing from his/her room. Resident #2 reported his/her wedding ring missing from his/her room. Resident #3 reported five pieces of jewelry missing from his/her room. Resident #4 reported a diamond ring, a gold necklace and several pieces of costume jewelry missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS118085,70M218,ALF,9/23/2011,"Resident #1 reported missing an electronic entertainment device and money from her/his room. Investigation was initiated, however no suspects were identified. The facility failed to provide a safe environment resulting in the loss of resident property. An unknown person was found responsible for abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +MS092853,70M218,ALF,11/30/2009,Witness #5 took money from residents without providing services. The facility failed to provide a safe environment resulting in the loss of resident property. Witness #5 was removed from the facility and the residents were reimbursed their money.,2,0,,, +MS120014,70M218,ALF,5/4/2012,"Resident #1 had a history of heart problems and high blood pressure. On or about 4:00 AM on May 4, 2012, Resident #1 reported to staff feeling nauseated, had problems breathing and a headache. Staff failed to evaluate the resident, report symptoms to appropriate staff or document the incident. Resident #1 was sent to the hospital after reporting the same condition on the morning of May 6, 2012 where she/he underwent surgery. The facility failed to appropriately monitor and intervene resulting in the potential for serious harm. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS132169,70M218,ALF,1/17/2013,Reported Perpetrator 2 (RP2) failed to follow facility policies regarding handling of medications received and verifying a medication order. Resident #1's narcotic pain medication of 90 pills went missing. RP2 is responsible for the loss of Resident #1's narcotic pain medications. The facility failed to provide a safe medication system and the failure is a violation of Oregon Administrative Rules.,3,0,Not Substantiated,Substantiated,Financial abuse +MS146011,70M218,ALF,2/6/2014,"Resident #1 did not receive her/his medication for several days resulting in increased frequency of coughing. The facility failed to provide a safe medication administration system. The facility also failed to maintain accurate medication administration records. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +MS148053,70M218,ALF,8/6/2014,"Resident #1 had increased aggressive behaviors towards others including staff. During an attempt to get away from Resident #1's grasp, RP2 threw water. Witness testimony and facility documentation reavealed that there was no care planning surrounding Resident #1's increased behaviors and how staff were to respond. Investigation concluded the facility failed to adequately address Resident #1's behavior resulting in loss of dignity. The failure is a violation of Oregon Administrative Rules.",2,,,, +MS148024,70M218,ALF,8/1/2014,"Resident #1 experienced a significant change of condition related to behaviors. The care plan failed to adequately address the behaviors or provide clear direction to staff after the significant change. The failure is a violation of resident rights, is considerd neglect of care and constitutes abuse.",2,,,,Neglect +MS148702,70M218,ALF,9/26/2014,"Resident #1 had $100 cash missing from a wallet located in her/his room. Witness testimony and facility documentation revealed 16 staff members had access to the resident's room during that timeframe and their had been rumors of previous thefts. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +MS151406,70M218,ALF,5/28/2015,"The facility failed to ensure a safe environment resulting in the loss of Resident #1's liquid narcotic medication. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for the theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +DL118670,70M219,ALF,10/28/2011,Resident #1 reported missing a video camera from her/his room. Investigation was started and law enforcement called. RP2 admitted to stealing Resident #1's camera. The facility failed to provide a safe environment. RP2 was held responsible for abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +DL121585,70M219,ALF,11/7/2012,Resident #1 and Resident #2 both reported money missing from their rooms. Reported Perpetrator 2 (RP2) was interviewed by Law Enforcement and admitted to taking the money. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +DL135279,70M219,ALF,12/4/2013,"Resident #1 had money stolen out of his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +DL146295A,70M219,ALF,1/30/2014,"Complainant reported suspected theft of money from Resident #1. Police were notified and an investigation was initiated. Surveillance tape showed RP2 taking money from Resident #1's room. RP2 later confessed to stealing money from Resident #1 and two other residents for approximately two years. RP2 was arrested for theft and employment terminated. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. RP2 was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +DL148881,70M219,ALF,10/10/2014,"Resident #1 and Resident #2 reported missing money out of their locked drawers. Local law enforcement was notified and an internal investigation was initiated. A hidden camera revealed RP2 taking money out of one of the resident's locked drawers and later admitted to the thefts. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. RP2 was found substantiated for theft of money, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +DL151889,70M219,ALF,7/6/2015,"The facility manages the administration of Resident #1's medication. On or about July 6, 2015, RP2 administered the wrong medication to Resident #1 and was identified immediately. There was no negative outcome as a result of the medication error. The facility failed to ensure medication was administered as ordered and is a violation of Oregon Administrative Rules.",2,,,, +GP105400,70M220,ALF,10/3/2010,"Resident #1's medication dosage was reduced and was correctly set out with written instructions. Reported Perpetrator 2 (RP2) put the higher dose of medications back in the file, and RP2 and Reported Perpetrator 3 (RP3) administered Resident #1 the incorrect, higher dose of medication for two days. Resident #1 became lethargic, non-responsive and was sent to hospital and returned later in the day.",3,0,Not Substantiated,Substantiated, +GP105506,70M220,ALF,10/14/2010,"Resident #1 was known to wander, had wondered out into the facility parking lot, and was care planned noting unfamiliar surroundings as an environmental factor. During an outing, Resident #1's care plan was not followed and he/she wandered off from the parking lot and was found within approximately 10 minutes.",2,0,,, +GP117142,70M220,ALF,6/2/2011,"Resident #1 had a medication order to be administered half sliding scale does of medication at bedtime. On 6/2/11, Reported Perpetrator 2 (RP2) administered a full dose of injection medication at approximately 9:30pm to Resident #1 instead of the half dose. RP2 notified Witness 1 and monitored Resident #1 as instructed. By approximately 12:30am, Resident #1 could not be woken, emergency service called and transported to hospital.",3,0,Not Substantiated,Substantiated, +GP118417,70M220,ALF,11/6/2011,Two cards of Resident #1's prescription narcotic medication and the associated narcotic sheets were discovered missing. The theft of narcotic medications resulted from actions of an unknown individual.,2,0,Not Substantiated,Substantiated,Financial abuse +GP120878,70M220,ALF,8/22/2012,Facility staff failed to properly follow Resident #1's care plan to not be left alone on the toilet. The failure is a violation of Oregon Administrative Rules.,2,0,,, +GP133703,70M220,ALF,7/3/2013,"Reported Perpetrator 2 (RP2) positioned Resident #1 inappropriately while his/her arm was caught behind his/her back, resulting in Resident #1 sustaining a fractured arm. The facility failed to provide appropriate care, which is a violation of Oregon Administrative Rules. RP2 is responsible for neglect of care, which is considered abuse.",3,,Not Substantiated,Substantiated,Neglect +RD148560,70M221,ALF,8/17/2014,It was discovered that Resident #1 was out of a routine medication. Twenty pills were missing and unaccounted for. The facility was unable to account for the missing pills. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BO149696A,70M221,ALF,8/1/2014,"Resident #1 did not receive pain medication as prescribed by his/her physician upon returning to the facility after sustaining a broken hip. Due to Resident #1's confusion, he/she was unable to request PRN pain medication. The facility failed to provide a safe medication administration system resulting in pain and suffering. The facility also failed to report incidents to APS in a timely manner. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BO149696B,70M221,ALF,8/1/2014,"Resident #1 was found on the floor of the whirlpool room. He/she was transported to the hospital and underwent surgery for a broken hip. The facility failed to adequately update Resident #1's care plan to address his/her needs. The facility also failed to report the incident to APS. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BO149696C,70M221,ALF,8/1/2014,Resident #1 eloped from the facility on several occasions. No injuries were sustained. The facility failed to appropriately care plan Resident #1 related to elopements and assure Resident #1 was safe. The facility also failed to report incidents to APS. The failures are a violation of Oregon Administrative Rules.,2,,,, +BO149696D,70M221,ALF,8/1/2014,Resident #1 was not receiving assistance to adequately meet his/her care needs. Resident #1's care plan was not reflective of his/her care needs. The care plan indicated Resident #1 needed minimal assistance. The facility failed to appropriately care plan Resident #1. The facility also failed to assure resident rights. The failures are a violation of Oregon Administrative Rules.,2,,,, +OR0001021002,70M221,ALF,10/26/2015,,0,,Not Substantiated,Substantiated, +OR0001031000,70M221,ALF,11/19/2015,,0,,Not Substantiated,Substantiated, +MV105901,70M222,ALF,10/19/2010,Resident #1 self medicated and kept his/her medications unlocked in his/her unlocked room. Narcotic medication was taken from his/his room; however all staff working that shift denied taking it. The facility reimbursed Resident #1 with new narcotic medications and encouraged him/her to lock up the medications.,2,0,,, +MV105944,70M222,ALF,12/7/2010,"Resident #1 reported money missing from his/her apartment. He/she had a lock box available for valuables, however never thought he/she needed to use it.",2,0,,, +MV117746,70M222,ALF,8/8/2011,"Resident #1 had a physician_x001A_s order to have blood drawn Monday, Wednesday, and Friday in order to monitor his/her response to blood thinning medication; however the order was misfiled and the blood draws did not occur as ordered. Resident #1 was transported to the hospital for treatment. The Facility_x001A_s failure to provide a safe medication system is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV117998,70M222,ALF,9/9/2011,Resident #1 was discharged from the hospital on 9/9/11 with changes to his/her medication dosages. The facility failed to provide a safe medication administration system resulting in Resident #1 not receiving the correct medication dosages for approximately four days.,2,0,,, +MV129394,70M222,ALF,2/25/2012,Resident #1 and Resident #2 was not administered their respective medications as ordered on 2/25/12 and 2/26/12. There were no documented negative outcomes. The facility failed to administered ordered medication. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MV118262,70M222,ALF,10/6/2011,"On 10/6/2011, Resident #1 discovered his/her camera was missing from his/her room. There were no suspects and the camera had not been found. An unknown individual is responsible for the loss of Resident #1's camera. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules. + + + +The Letter of Determination was completed at a later date due to the extended period of time between the incident date and processing by the Department.",2,0,Not Substantiated,Substantiated,Financial abuse +MV132876,70M222,ALF,3/15/2013,"Reported Perpetrator 2 (RP2) admitted taking money from the resident's personal incidental fund accounts at the facility. The facility failed to protect the residents from financial exploitation. The failure is a violation Oregon Administrative Rules. RP2 took the funds, which is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +MV133213,70M222,ALF,5/11/2013,"Resident #1's medication order indicated diagnoses of dementia, hallucinations and anxiety. Resident #1 was also a fall risk. It was determined Resident #1 was appropriate to move into the facility. In the early morning hours of 5/11/13, Resident #1 rolled out of bed and hit his/her head. He/she was transported to the hospital and found to have no injury. In the afternoon of 5/11/13 Resident #1 was found outside. He/she had fallen from their scooter and hit their head sustaining a laceration to the head. He/she was transported to the hospital again and received five staples in his/her head. The facility failed to perform adequate screening and assessment of Resident #1 and service plan accordingly prior to admission to the facility. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV129849,70M222,ALF,4/16/2012,"Resident #1 experienced a fall on 3/16/12 followed by mobility decline and increased pain and edema in his/her legs. The facility did not attempt to arrange an x-ray. When Resident #1 received the x-ray on 4/13/12 it was found that he/she had a hip fracture. The facility failed to assess Resident #1 for a change of condition and seek timely medical treatment regarding the fall injury. The facility also failed to update Resident #1's service plan to address fall interventions due to fall history. The failures are a violation of resident rights, are considered neglect of care and constitute abuse. A civil penalty is warranted; however, one will not be issued due to the extended period of time between the incident date and processing by the Department.",3,,,,Neglect +MV148668,70M222,ALF,9/21/2014,"Resident #1 struck Resident #2 in the back. Resident #1's care plan stated he/she was to be monitored closely in the dining room and around other residents due to him/her hitting other residents. Resident #1 was not being monitored by staff when he/she struck Resident #2. The facility failed to follow Resident #1's care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA105745A,70M223,ALF,12/2/2010,"Facility staff did not follow the care plan of Resident #1 which indicated staff was to assist the resident to bed and check on him/her every 2 hours during the night. The resident was not assisted to bed but left up in his/her chair with his/her feet in the down position, which resulted in swelling to the resident's legs.",2,0,,,Neglect +BA105745B,70M223,ALF,12/2/2010,"Facility staff failed to follow physician orders with respect to Resident #1's need to have his/her feet elevated while he/she was in bed at night. As a result of the Facility's failure to do so, the resident's condition, over time, did not improve or got worse.",2,0,,,Neglect +BA105745C,70M223,ALF,12/2/2010,Facility staff failed to follow Resident #1's care plan by ensuring that he/she was toileted on schedule and making sure he/she had his/her incontinent products on before he/she went to bed. The staff's failures resulted in the resident experiencing episodes of incontinence.,2,0,,,Neglect +BA118554,70M223,ALF,10/14/2011,"Staff did not reorder Resident #1's blood pressure medication and replaced with antihistamine between October 1 through 14, 2011. Resident #1 was sent to the hospital for treatment twice for chest pains and significant weight gain. The facility failed to ensure a safe medication administration system resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +BA129364,70M223,ALF,12/8/2011,Resident #1 was administered another resident's medication resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +OT129551,70M223,ALF,3/19/2012,RP2 failed to document Resident #1 received a specific medication when the resident left the building for a few days with her/his medication. Medication was discovered missing during a medication count. Discovery of the documentation error occurred after Resident #1 was called to confirm she/he had the specific medication. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +OT128999,70M223,ALF,1/17/2012,"Resident #1 has scheduled medication to reduce tremors. On January 17, 2012, at approximately 4:30 AM RP3 administered medication to Resident #1 that was scheduled for 6:00 PM. Resident #1 experienced complications as a result of this medication error. On the same day, RP2 administered medication at 3:00 PM that was scheduled for 6:00 PM. RP3 rearranged the medication cart without authorization. The facility failed to ensure Resident #1 was administered medication as ordered resulting in minor harm. The failure was a violation of Oregon Administrative Rules. RP3 was found responsible for abuse.",2,0,Not Substantiated,Substantiated,Neglect +OT129553,70M223,ALF,3/17/2012,Resident #1 requires scheduled medication at 5:00 AM. RP2 failed to administer the medication and failed document the reasoning at the time of the incident. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO12057,70M223,ALF,5/9/2012,"The facility failed to ensure service plans were reflective of residents_x001A_ status and provided clear direction regarding care for Resident #3 and Resident #6. The facility failed to ensure Resident #3 and #6 were evaluated and monitored according to their needs and referrals were made to the RN for assessment. The facility failed to provide RN assessments for Resident #3 and #6, who experienced significant changes in condition. Resident # 3 developed two stage II pressure ulcers and Resident #6 had a chronic scalp wound that worsened. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BA120074,70M223,ALF,2/25/2012,The facility failed to administer medication as ordered resulting in receiving the wrong dosage for two and a half months. There were no know negative outcome as a result of the error. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA120576,70M223,ALF,4/3/2012,The facility refused to provide as needed medication to Resident #1 while she/he was out of the facility. The facility failed to provide a safe medication administration system resulting in the potential for harm to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA120081,70M223,ALF,3/15/2012,RP2 transcribed an as needed ordered pain medication onto the Medication Administration Record resulting in Resident #1 receiving a reduced dose on two occassions. The facility failed to ensure medication was administered as ordered resulting in the potential for harm to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA120067,70M223,ALF,3/7/2012,Resident #1_x001A_s Medical Administration Record (MAR) was not transcribed correctly. Resident #1 was administered two discontinued medications and his/her eye drops were not administered as prescribed due to the MAR errors. Resident #1 did not have a negative outcome from the errors. The facility failed to have a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA120069,70M223,ALF,3/12/2012,Resident #1 was given medications that belonged to another resident. There was no negative outcome to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,0,,, +CO13031,70M223,ALF,3/21/2013,A Licensed Condition was issued effective 3/29/13 due to continued non compliance with Oregon Administrative Rules and evidenced by preliminary information from survey revisit #3 completed 3/21/13. Please see Condition ALFCD13-002 terms for details.,2,0,,, +BA121541,70M223,ALF,9/11/2012,Reported Perpetrator 2 (RP2) made Resident #1 feel uncomfortable due to an unsolicited hug. The facility failed to provide a safe and secure environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +BA121665,70M223,ALF,11/13/2012,"Resident #1 was found in his/her room on the floor with abrasions to his/her leg and head. Facility documentation stated Resident #1 had two prior un-witnessed falls. There was no documentation prior to the third fall indicating what preventative measures were taken to address the issue. The facility failed to properly care plan related to falls for Resident #1. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BA132557,70M223,ALF,10/4/2012,"Resident #1 required daily assistance with changing. On October 4, 2012, Resident #1 was observed with a large bruise on her/his chest area. The facility failed to provide adequate care and monitoring as care planned. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +BA146222,70M223,ALF,3/31/2011,"Resident #1 had a history of falls and was care planned for a fall mat on the floor while in bed. On or about March 31, 2011, Resident #1 fell out of bed resulting in an abrasion to the forehead. The facility failed to ensure the service plan was followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. This notice is being sent at a later date due to the timeframe between the investigation date and when it was submitted to the Department.",2,,,,Neglect +BA146566,70M223,ALF,10/3/2012,"Resident #2 had a history of aggressive and paranoid behaviors. On two separate occasions, Resident #2 physically harmed Resident #1 resulting in injury. The facility failed to appropriately monitor and care plan for Resident #2's behaviors. The failures are violations of resident rights, are considered neglect of care and constitutes abuse. This notification was processed at a later date due to the timeframe between the investigation and when it was closed.",2,,,,Neglect +BA133603,70M223,ALF,5/15/2013,"Resident #1 required assistance with transferring and toileting. Resident #1 also had a history of falls and attempting to self-transfer. Witness testimony and facility documentation revealed facility staff failed to answer Resident #1's call light in a timely manner resulting in falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BA146967,70M223,ALF,1/29/2013,"Resident #1 experienced a fractured rib after a cabinet fell on her/him when attempting to get toilet paper in the front lobby bathroom. Facility later secured the cabinet to the wall to prevent future occurrence. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty was warranted, however one was not issued due to the length of time between the investigation and when it was submitted to the Department for processing.",3,,,,Neglect +BA120072,70M223,ALF,3/13/2012,The facility failed to keep Resident #1's Medication Administration Record accurate resulting in the administration of a discontinued medication. No negative outcome was observed as a result of the error. The failure is a violation of Oregon Administrative Rules.,2,,,, +BA148132,70M223,ALF,6/13/2014,"Resident #1 experienced multiple recent falls and a history of refusing to call for assistance. Multiple bruises were discovered on her/his body. Witness testimony and facility documentation revealed a lack of adequate interventions to address her/his falls. Investigation concluded that the facility failed to adequately care plan after Resident #1 experienced a signification change of condition. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +BA150033,70M223,ALF,9/17/2014,"Resident #1 had a history of falls and confusion. The facility failed to adequately care plan and monitor Resident #1 resulting in multiple falls with injury. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BA150047,70M223,ALF,11/26/2014,Resident #1 returned from the hospital with a diagnosis of brain bleed and did not discontinue the blood thinning medication for a few days. The facility failed to ensure a safe medication administration system resulting in the potential for harm and is a violation of Oregon Administrative Rules.,2,,,, +RB116334,70M225,ALF,2/10/2011,"Resident #1 experienced pain due to a medical condition, requested multiple times for his/her PRN pain medication but did not receive the PRN pain medication until approximately 1 1/2 hours later. He/she was upset of the delay in getting his/her prescribed PRN pain medication.",2,0,,, +RB117654,70M225,ALF,8/5/2011,RP2 administered the wrong medications to Resident #1 with no negative outcome. The facility failed to provide a safe medication administration system resulting in the potential for harm.,2,0,,, +RB117749,70M225,ALF,8/9/2011,Resident #1's physician's order was transcribed incorrectly onto her/his Medication Administration Record resulting in the resident not receiving medication as ordered. There was no harm as a result of the error.,2,0,,, +RB129118A,70M225,ALF,1/30/2012,"Resident #1 was care planned for staff assistance with toileting needs three times per shift; staff to apply cream to any skin reddening or opened areas; and to observe and report any skin breakdown. Resident #1 was transported to the hospital and his/her perineal area and buttocks were excoriated, raw, and bleeding. The facility failed to follow Resident #1_x001A_s care plan and monitor and report his/her skin issues. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +RB129118B,70M225,ALF,1/30/2012,The facility failed to timely assess and intervene after Resident #1 experienced a fall with injury while he/she was being monitored for a new medication. The failure is a violation of Oregon Administrative Rules.,2,0,,, +RB129374,70M225,ALF,2/29/2012,"Resident #1 and Resident #2 were noted to have behaviors; however staff did not have specific instructions or interventions to address behaviors. An altercation occurred between Resident #1 and Resident #2 at the snack counter, and neither suffered any injury. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,,, +RB129601,70M225,ALF,3/22/2012,Resident #1 was care planned as known to make sexual comments to caregivers and interventions instructing staff how to respond. Resident #1 was found in Resident #2's room stating that he/she kissed Resident #2. Resident #2 had cognitive impairments and was unable to consent. There was no documented evidence indicating Resident #2 experienced any distress. The facility failed to properly plan care and implement interventions regarding Resident #1's behaviors and keeping all other residents safe. The failure is a violation of Oregon Administrative Rules.,2,0,,,Neglect +RB129938,70M225,ALF,4/21/2012,Resident #1 discovered money missing from his/her room. An unknown individual is responsible for the theft of Resident #1's money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +RB120973,70M225,ALF,8/30/2012,"The facility failed to seek clarification from an unreadable medication change from Resident #1's physician on 8/30/12 until 9/4/12, approximately five (5) days. Resident #1 experienced no observable harmful outcome. The facility failed to report nine (9) incidents of readings over 300 and three (3) incidents under 60 to his/her physician. Resident #1 experienced no observable harmful outcome; however he/she was exposed to potential for harm. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +RB121190,70M225,ALF,9/30/2012,"Resident #1's prescribed scheduled narcotic pain medication was not timely reordered to refill the prescription. Resident #1 didn't experience any more pain than usual; however did suffer from the sweats and was restless. The facility's protocol was not followed. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +RB132711,70M225,ALF,3/19/2013,The investigation revealed Reported Perpetrator 2 (RP2) made inappropriate comments to Residents #1 and #2. The facility failed to protect Residents #1 and #2 from verbal abuse. The failure is a violation of Oregon Administrative Rules. RP2 is responsible for verbal abuse.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +RB133116,70M225,ALF,5/1/2013,"It was reported Resident #1 was a fall risk and fell on multiple occasions. Supports in place for Resident #1's fall risk was a call pendant, which Resident #1 did not remember to use and for staff to remind Resident #1 to use it. Resident #1 fell and sustained a broken bone. The facility failed to properly care plan. The failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB133113,70M225,ALF,5/1/2013,"The facility agreed to re-admit Resident #1 from the hospital, knowing he/she needed to be fed by staff but failed to have enough staff on duty to do so. They asked family members to be present during meal time in order to help feed Resident #1. The facility failed to plan for Resident #1's total care. The failure is a violation of Oregon Administrative Rules.",2,,,, +RB145671,70M225,ALF,1/6/2014,"Resident #1 was not showered for fourteen days between 11/14/13 and 11/28/13, eleven days between 11/28/13 and 12/09/13, twelve days between 12/09/13 and 12/23/13, and fourteen days between 12.26.13 and 01/09/14. Resident #1 was not on a set showering schedule, and was not offered showering in a timely manner after an initial refusal in each incidence. The facility failed to provide adequate hygiene assistance for Resident #1 which is neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +RB146197,70M225,ALF,11/11/2013,"Resident #1 was to be bathed three times a week as specified in his/her service plan. Between December 29th 2013 and February 18th 2014, documentation indciated bathing was not provided as care planned. The facility failed to provide bathing services for Resident #1. This failure is neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +RB146983,70M225,ALF,3/2/2014,"Resident #1 received two different types of narcotic pain medication; however they ran out and he/she missed doses off and on between 3/5/14 and 3/18/14 causing increased agitation and pain. The facility failed to have a safe medication administration system to ensure medication was available. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RB147248,70M225,ALF,4/21/2014,"The facility failed to ensure Resident #1's chronic infection test was completed as ordered. Resident #1 was found to have an active infection. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +RS164256,70M225,ALF,1/5/2016,"The facility failed to appropriately care plan and implement interventions regarding behaviors and failed to monitor Resident #1 and Resident #2 to ensure safety. Resident #1 and Resident #2 had an altercation in their shared room. Resident #1 was transported to the hospital with a head injury which required staples. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES120517,70M226,ALF,7/13/2012,"Resident #1 was found around 7:00 AM on July 13, 2012 asleep in her/his wheelchair and soaked in urine. Resident #1's wound worsend. Resident #1's care plan directed staff to check on the resident every night, check for incontinence and ensure the resident was using her/his breathing machine. RP2 and RP3 were assigned caregivers responsible for Resident #1 however did not check on the resident as care planned. The facility failed to ensure Resident #1's care plan was followed resulting in harm. The failure is a violation of Oregon Administrative Rules. RP2 and RP3 were both held responsible for neglect of care and constitues abuse.",2,0,Not Substantiated,Substantiated,Neglect +ES133150,70M226,ALF,5/6/2013,"Resident #1 and Resident #2 reported loss of money from their respective rooms sometime between May 6 and May 7, 2013. The facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for theft, is considered financial exploitation and constitutes abuse.",0,0,Not Substantiated,Substantiated,Financial abuse +ES133441,70M226,ALF,6/5/2013,"Resident #1 reported loss of $20 from her/his locked room. The facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES133498,70M226,ALF,5/15/2013,"RP2, a new medication aide tried to give Resident #1 another resident's medication. Resident #1 was aware of what medications she/he took and had to repeat several times to RP2 that the medications were incorrect. The facility failed to provide a safe medication administration system resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +ES133237,70M226,ALF,5/14/2013,"Resident #1 reported the loss of $300. There have been multiple thefts at the facility. Facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for theft of money, is considered financial exploitation and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +ES133678,70M226,ALF,6/28/2013,"Resident #1 reported $125 cash missing from a wallet kept in a storage bin on her/his mobility devise. There have been multiple recent thefts at the facility. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,300,Not Substantiated,Substantiated,Financial abuse +ES133958,70M226,ALF,7/24/2013,"Resident #1 reported missing a jar full of change estimated at $30 missing from the locked cabinet in her/his room. There have been multiple thefts reported at the facility. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,300,Not Substantiated,Substantiated,Financial abuse +ES133683,70M226,ALF,7/3/2013,"Resident #1 reported $50 missing from a wallet kept in a vest pocket and is only removed at night when going to bed. There have been multiple thefts reported at the facility. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES133720,70M226,ALF,7/8/2013,"Resident #1 reported $20 cash missing. Resident #1 kept the cash on her/him unless in her/his room. There have been multiple thefts reported at the facility. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES133814,70M226,ALF,7/15/2013,"Resident #1 reported $25 cash missing from the locked cabinet in her/his room. Resident #1 keeps the key to the locked cabinet with her/him and always locks the door when not in room. RP2 was suspected but investigation was unable to verify who took Resident #1's money. There have been multiple thefts reported at the facility. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES133236,70M226,ALF,5/15/2013,RP2 squeezed Resident #1's penis causing pain while providing toileting assistance. The facility failed to ensure Resident #1 was treated with respect and dignity. The failure is a violation of Oregon Administrative Rules. RP2 was substantiated for physical abuse.,2,,Not Substantiated,Substantiated,Physical Abuse +ES133673,70M226,ALF,6/26/2013,"Resident #1 reported money missing from her/his wallet on two separate occasions. Internal investigation was conducted. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES133617,70M226,ALF,6/22/2013,"Resident #1 reported $40 cash and jewelry taken from her/his room. No suspects were identified. The facility failed to provide a safe environment and is a violation of Oregon Administrative Rules. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ES133853,70M226,ALF,6/18/2013,"Resident #1 and Resident #2 had a long history of verbal altercations. Resident #1 found a extremely negative note taped to her/ his door. The facility failed to timely address and appropriately care plan residents' behaviors resulting in continued negative altercations. The failures are violations of resident rights, are considered neglect of care resulting in verbal/emotional abuse.",2,,,,Verbal/Mental abuse +ES134919,70M226,ALF,10/31/2013,"Facility reported $345 of three residents PIF (Personal Incidental Funds) were taken from the lockbox held by the facility. Witness testimony and facility documentation revealed both the lockbox and the file cabinet holding the lockbox were not properly secured resulting in the loss of funds. The facility failed to provide a safe environment resulting in theft. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown person was also held responsible for financial exploitation and constitutes abuse.",3,400,Substantiated,Substantiated,Financial abuse +ES146315,70M226,ALF,3/10/2014,"The facility failed to adequately administer Resident #1's medications. Resident #1 missed 5 doses of medication and suffered from diarrhea symptoms as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +ES147022,70M226,ALF,5/2/2014,The facility failed to appropriately supervise Resident #1 to ensure he/she leashed their dog when taking it outside. Resident #1's dog was able to get out without a leash several times. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES147413,70M226,ALF,6/11/2014,The facility failed to protect Resident #1 from emotional abuse. Facility staff had Resident #1's pet taken away against Resident #1's consent. Resident #1 suffered emotional distress due to having his/her pet taken from them. This is considered mental abuse and is a violation of Oregon Administrative Rules.,2,,,,Verbal/Mental abuse +ES148074B,70M226,ALF,7/31/2014,The facility failed to follow Resident #1's care plan. Resident #1 was care planned to receive no meals prior to their scheduled surgery. Resident #1 was given a meal and his/her surgery had to be re-scheduled. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES148074A,70M226,ALF,7/31/2014,The facility failed to provide a safe environment in relation to Resident #2 making threats to Resident #1. This failure is a violation of Oregon Administrative Rules.,2,,,, +ES149453,70M226,ALF,12/2/2014,"Resident #1 had money go missing from his/her PIF account. The money was taken by Reported Perpetrator #2 and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES159985,70M226,ALF,1/21/2015,"The facility failed to administer medication as ordered. Several residents received their medication late, or received other residents medications by mistake. This failure is a violation of Oregon Administrative Rules.",2,,,, +ES146999,70M226,ALF,5/5/2014,"Resident #1 and Resident #2 had money and checks go missing from his/her room. The money and checks were taken by Reported Perpetrator #2 (RP2) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1 and #2's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES153328,70M226,ALF,10/23/2015,"The facility failed to ensure care staff followed Resident #1s care plan to use a gait belt when assisting with transfers. Resident #1 fell and sustained an injury requiring staples. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB116337,70M227,ALF,2/14/2011,"A resident of the Facility and his/her spouse who shared the same room were known to get into physical altercation which sometimes resulted in injury to one or the other residents. While Facility staff intervened after each incident and attempted to put measures in place to prevent reoccurrence, the residents continued to have altercations, resulting in an unsafe environment.",2,0,,, +HB129790,70M227,ALF,4/14/2012,RV1 hit RV2 on two occasions. After investigation it was determined that staff is addressing RV1's behavior problems appropriately.,0,0,,, +HB133844,70M227,ALF,7/18/2013,"Resident #4 was verbally and physically abusive to other residents and was engaged in physical altercations on at least four occasions before any preventative measures were put into place. It was reported that Reported Perpetrator 2 (RP2) was informed of Resident #4's behavior on multiple occasions before putting preventative measures into place. The facility failed to provide a safe environment for residents. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 failed to intervene in a timely manner, which is considered neglect of care and constitutes abuse.",2,,Substantiated,Substantiated,Neglect +HB133874,70M227,ALF,7/23/2013,Resident #1 discovered a wallet with cash and credit cards taken from her/his room. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for financial exploitation and constitutes abuse.,2,,Not Substantiated,Substantiated,Financial abuse +HB134296,70M227,ALF,6/11/2013,"Resident #1 was independent with all activities of daily living and did not have a care plan relating to a diagnosis of memory impairment. Resident #1 reported leaving $200.00 in his/her apartment while going out with a family member. The money was later missing. Resident #1 stated his/her apartment door was locked. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. An unknown person took the money and is responsible for financial exploitation, which constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB134404,70M227,ALF,9/12/2013,"Resident #1's Care Plan states he/she is incontinent of bowel and bladder and needs one person to assist with transfers. On August 8, 2013, Resident #1 was left on the toilet for 20 minutes when staff forgot they left him/her there. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB146118,70M227,ALF,2/19/2014,"Resident #1 required assistance with toileting. Resident #1 was transferred to the toilet and left unattended for over two hours before self-transferring. Resident #1 did not have her/his call pendant and there was no manual call button in the bathroom. The facility failed to follow the care plan and failed to have a call button in the bathroom. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB146932,70M227,ALF,4/30/2014,"Resident #1 reported missing a bottle of cologne/perfume and notified staff. Local law enforcement were notified and an internal investigation conducted. Witness testimony revealed Resident #1 consistently locks her/his door. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB147429,70M227,ALF,6/17/2014,"Resident #1 required and was care planned for full assist with all ADLs (Activities of Daily Living). On or about the morning of June 14, 2014 Resident #1 was observed in her/his recliner wearing the same clothes from the day before and incontinent of feces and urine. She/he was unable to reach her/his call light and indicated that no one had come to help her/him. RP2 was assigned to provide care to Resident #1. The facility failed to ensure Resident #1's care needs were met and is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care which constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +HB147595,70M227,ALF,6/28/2014,"Resident #1 and #2's medication cards were discovered missing from the unsecured medication room. An investigation was initiated, however no suspects were identified. The facility failed to provide a safe medication administration system resulting in the loss of residents' medications. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",2,,Substantiated,Substantiated,Financial abuse +HB150244,70M227,ALF,2/12/2015,"The facility failed to maintain a functioning call light system resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH116398,70M228,ALF,2/16/2011,Resident #1 was administered his/her heart medication when his/her blood pressure was low.,1,0,,, +BH118134,70M228,ALF,6/21/2011,"Reported Perpetrator 2 entered Resident #1's room without permission, which upset Resident #1. The facility failed to assure resident rights and is a violation of Oregon Administrative Rules.",2,0,,, +BH117693,70M228,ALF,7/9/2011,"The facility failed to follow Resident #1_x001A_s care plan and failed to monitor and implement interventions when his/her alert pendant was not working. Resident #1 suffered injuries from a fall in his/her room, was on the floor for approximately 14 hours before staff found him/her and was transported to the hospital for treatment.",3,300,,,Neglect +BH118610,70M228,ALF,7/20/2011,"It was discovered on or about July 20, 2011 that Resident #1's narcotic pain medications were replaced with other medication. RP2 was suspected, however were unable to determine who took the medications. The facility failed to provide a safe environment resulting in the loss of medication. An unknown individual was found responsible for abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +BH146306,70M228,ALF,3/3/2014,"Resident #1 was administered Resident #2's medication in error. Resident #1 was transported to the hospital for treatment. The facility failed to ensure a safe medication administration system and failed to ensure staff followed facility policies. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BH150649,70M228,ALF,2/16/2015,"The facility failed to timely address Resident #1's change of condition of sores on his/her toes. It was approximately 8 days until the sores were addressed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BH159765,70M228,ALF,12/26/2014,"On 12/26/14, Resident #1 felt a pinch and stated it hurt during a transfer. Later, blood was noticed coming from his/her right elbow revealing a skin tear. He/she also had a large dark discoloration on his/her right upper/inner arm of unknown origin. The facility failed to ensure safe environment with safe transfers. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +RB116299,70M229,ALF,2/1/2011,RP2 administered Resident #1 a second dose of her/his medications. The resident did not experienced any negative effects as a result of the medication error. The facility failed to provide a safe medication administration resulting in the potential for harm.,2,0,,, +RB116171,70M229,ALF,1/18/2011,RP2 did not follow the care plan as directed to check in on Resident #1 and Resident #2 every two hours. RP2 called the residents rude after she/he was confronted about not checking in on them. The facility failed to ensure resident rights resulting in the loss of dignity.,2,0,,, +RB116242,70M229,ALF,1/27/2011,The facility failed to ensure a safe environment resulting in the loss of resident property.,2,0,Not Substantiated,Substantiated,Financial abuse +RB117910,70M229,ALF,9/5/2011,The facility failed to provide a safe environment resulting in the loss of money from Resident #1's room. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Neglect +RB129255,70M229,ALF,2/9/2012,"It was reported that Resident #1 had been dropped 3 times. No falls or incidents were reported. Resident #1_x001A_s care plan states that he/she transfers independently and will call for assistance when needed. The facility failed to update Resident #1_x001A_s care plan. + +The failure is a violation of Oregon Administrative Rule.",2,0,,, +RB129359,70M229,ALF,2/27/2012,Resident #1 reported money missing from his/her wallet. An unknown individual was determined to be responsible for the theft of money. The facility failed to provide a safe environment for residents resulting in loss of property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +RB132199,70M229,ALF,1/20/2013,Resident #1 reported $50.00 missing from his/her wallet. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Not Substantiated,Financial abuse +RB132684,70M229,ALF,3/13/2013,Resident #1 reported $25.00 missing from his/her wallet which was in the lock box in his/her room. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment resulting in the loss of Resident #1's money. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated, +RB133064,70M229,ALF,4/12/2013,Resident #1 was missing $200.00 from his/her wallet. An unknown individual was determined to be responsible for the loss of Resident #1_x001A_s money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +RB134959,70M229,ALF,11/3/2013,"Resident #1 reported narcotic pain medication missing from his/her room. An unknown individual was found responsible for the theft of Resident #1's medications which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,350,Substantiated,Substantiated,Financial abuse +RB135068,70M229,ALF,10/15/2013,"Resident #1 was transferred on 10/15/13 using a gait belt. He/she complained during the transfer of pain. The care plan in place at the time of the incident addressed how to transfer Resident #1 not using the gait belt. The facility failed to follow Resident #1's care plan resulting in Resident #1 sustaining broken ribs. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +RB135457,70M229,ALF,12/14/2013,Resident #1 reported money missing from the seat section of his/her walker. The facility failed to provide a safe environment for residents. The failure is a violation of resident rights.,2,300,,, +RB148120,70M229,ALF,8/11/2014,Resident #1 was administered Resident #2's medications. Resident #1's physician was notified. Resident #1 was sent to the hospital for monitoring and returned to the facility. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +RS150597,70M229,ALF,3/17/2015,Resident #1 was administered another resident's medication. Resident #1 had no negative outcome. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +RS151142,70M229,ALF,1/1/2015,"Resident #1 was care planned as a total assist with grooming and hygiene; however he/she often refused teeth brushing and flossing. The facility failed to follow the care plan; failed to provide oral care; and failed to care plan appropriately to ensure adequate hygiene. Resident #1's teeth and gum lines were unclean. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +RB150062,70M229,ALF,1/12/2015,Fifty-one narcotic pain medication pills were missing from the facility. An unknown individual was found responsible for the loss of resident medication which constitutes financial exploitation. The facility failed to provide a medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +RS152623A,70M229,ALF,8/17/2015,"Resident #1 was administered a second anti-psychotic medication the same day he/she had already received a dosage along with additional narcotic pain reliever. Resident #1 was described as ""completely out of it"" and drooling. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +RS152623B,70M229,ALF,8/17/2015,"Resident #1 experienced several falls during a seven day period of time, with no amendments to his/her care plan. Resident #1 was not assessed for a change of condition. Resident #1 sustained skin injuries. The facility failed to update Resident #1's care plan to address fall interventions and assess for a change of condition. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +OR0001073800,70M229,ALF,3/8/2016,,1,,Not Substantiated,Substantiated, +KF106002,70M230,ALF,12/25/2010,"A resident of the Facility was temporarily placed in the Facility's Memory Care Community (MCC) for closer observation, due to the residents increased exit seeking and elopement earlier in the day. While in the MCC, the resident was let out of the Facility by staff. The resident eloped and sustained minor injury.",2,0,,,Neglect +KF103853,70M230,ALF,3/26/2010,A resident who was declining following a medical episode was noted on his/her next trip to the hospital to have a raw and reddened genital and buttocks.,1,0,,, +KF116525,70M230,ALF,5/13/2010,A resident of the Facility was left in soiled incontinence products for approximately 12-hours. The resident was care planned to receive frequent assistance with toileting and incontinence. Facility staff did not follow the resident's care plan resulting in unreasonable discomfort.,2,0,,,Neglect +KF105562,70M230,ALF,10/26/2010,"Two Facility staff members, Reported Perpetrator #2 (RP2) and Reported Perpetrator #3 (RP3) knowingly did not follow a residents service plan, resulting in that resident falling and sustaining moderate injury. The Facility had provided clear and adequate training and instruction to both staff members.",3,0,Not Substantiated,Substantiated,Neglect +KF104075,70M230,ALF,4/20/2010,Facility staff failed to provide a resident of the Facility with services he/she was paying for until the resident reminded care staff of the change to his/her care. Direct care staff was not aware the resident's care plan had been updated.,1,0,,, +KF117096,70M230,ALF,5/21/2011,"A resident of the Facility who displayed symptoms of a urinary tract infection was ordered by his/her physician to have a urine test performed. Facility staff took the resident's sample, but failed to test it until the sample was no longer viable. The Facility waited a considerable amount of time before attempting to retest the resident, resulting in antibiotics not being prescribed until approximately 7 days after the initial concern was stated.",2,0,,,Neglect +KF117255,70M230,ALF,6/16/2011,The facility failed to provide a safe environment resulting in the loss of money from residents' room. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +KF117881,70M230,ALF,8/31/2011,"Resident #1 was scheduled to receive pain medication at the evening medication pass. Resident #1 was out of the facility at the time of the evening medication pass. Upon his/her return to the facility that evening, he/she was not given his/her medication. The medication administration record (MAR) showed that the medication was given. The facility failed to have an accurate medication administration record. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF132743,70M230,ALF,3/18/2013,"Resident #1 had frequent falls and would roll out of bed. As a safety precaution, a fall pad was to be in placed on the floor at all times when Resident #1 was in bed. A care giver did not replace Resident #1_x001A_s fall pad after caring for him/her. Resident #1 rolled off the bed and hit the floor sustaining a gash to his/her forehead. The facility failed to follow Resident #1_x001A_s service plan. The failure is a violation of Oregon Administrative Rules",2,0,,, +KF133003,70M230,ALF,4/16/2013,"Resident #1 had a medical condition that required a specific medication to be administered at specific times. The facility was responsible for administering Resident #1_x001A_s medications. Medications were given to Resident #1, but staff did not verify that Resident #1 took the medications. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF120488,70M230,ALF,7/11/2012,"Resident #1 was a fall risk and had several falls between May and July, 2012. One fall resulted in Resident #1 sustaining broken ribs. There were no amendments to his/her service plan after each fall. The facility failed to update Resident #1_x001A_s service plan to address fall interventions. The failure is a violation of Oregon Administrative Rules.",2,0,,, +KF133842,70M230,ALF,7/18/2013,"Resident #1 eloped from the facility and refused to return on July 18, 2013. No injuries were sustained. Resident #1 had experienced increased agitation and behaviors. Resident #1_x001A_s physician was not notified regarding his/her change in behaviors. The facility failed to assess Resident #1 for a change of condition and service plan accordingly. The failures are a violation of Oregon Administrative Rules.",2,,,, +KF134624,70M230,ALF,8/29/2013,"Resident #1 had a history of falls, a medical condition that caused him/her to be unbalanced on his/her feet as well as poor eye site. Resident #1 had an unwitnessed fall in his/her apartment resulting in hitting his/her head and sustaining a laceration, and was transported to the hospital. While at the hospital it was discovered that Resident #1 had a wound on his/her coccyx. Resident #1_x001A_s care plan indicated he/she needed no assistance. Facility staff was unaware of Resident #1_x001A_s wound. Resident #1_x001A_s care plan did not reflect his/her increasing care needs. Staff indicated they do not routinely look at care plans. The facility failed to appropriately plan care for Resident #1 resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF147720,70M230,ALF,7/10/2014,Reported Perpetrator 2 (RP2) confronted Resident #1 in an inappropriate manner in a public area of the facility. Resident #1 was visibly upset and crying. RP2 was found responsible for verbal abuse. The facility failed to provide a safe environment for Resident #1. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +KF146988,70M230,ALF,5/3/2014,"Resident #1's care plan listed cognitive/behavioral issues that required moderate supervision, guidance and redirection. Resident #1 left the building by cab to go home and visit. Facility staff let him/her leave due to not knowing if he/she was to leave the facility or not. Resident #1 returned to the facility by cab with no negative outcome. The facility failed to appropriately care plan Resident #1 regarding cognitive/behavior issues and being kept in a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,,, +KF148276,70M230,ALF,8/24/2014,It was discovered that Resident #1 had five pain pills missing on 8/25/14. The pills had not been counted since 8/24/14 and were accounted for at that time. The facility failed to provide a system that prevents thefts and misuse of medications. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF149247,70M230,ALF,11/16/2014,Facility staff was to conduct frequent checks on Resident #2 due to him/her being involved in a previous altercation. Resident #2 was left unattended and hit Resident #1. The facility failed to follow Resident 2's service plan regarding frequent checks. The failure is a violation of Oregon Administrative Rules.,2,,,, +KF150088,70M230,ALF,1/30/2015,"Resident #1 sustained multiple falls while at the facility. The facility failed to update Resident #1_x001A_s service plan to address fall interventions and assure he/she had a call light within reach. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +KF150165,70M230,ALF,2/5/2015,"Resident #1 experienced five falls before an assessment was completed to address falls. On 2/5/15, Resident #1 had a fall that resulted in fractured ribs. The facility failed to adequately update Resident #1's care plan to address falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +KF151020,70M230,ALF,4/21/2015,Resident #1's physician ordered on 3/31/15 that oxygen for Resident #1 was to be checked every hour. Resident #1's care plan was updated on 4/21/15 to check his/her oxygen every hour. The facility failed to follow physician_x001A_s order regarding checking oxygen. The failure is a violation of Oregon Administrative Rules.,2,,,, +OR0001036000,70M230,ALF,12/4/2015,,0,,Not Substantiated,Substantiated, +BH116727,70M231,ALF,3/30/2011,"The facility failed to routinely check that medications on the narcotic sheets were also recorded on the Medication Administration Records (MARS). For approximately eight months, Reported Perpetrator 2 (RP2) took narcotic medications, recorded on the narcotic sheets and did not record the medications on the MARS or administer the medications to Residents 1-6. There was no evidence indicating residents suffered additional pain. The facility failed to provide a safe system that prevents theft or misuse of narcotic medications. The Facility_x001A_s failures are a violation of resident rights, are considered neglect and financial exploitation and constitute abuse.",3,350,Substantiated,Substantiated,Financial abuse +BJ104361,70M231,ALF,5/18/2010,"The facility failed to provide a safe environment resulting in the loss of a residents narcotic pain medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Financial abuse +MS148542,70M233,ALF,9/14/2014,"Resident #1 and Resident #2 were involved in an altercation. Both residents are cognitively impaired and have a history of physical altercations. Resident #1 punched Resident #2 in the face causing injury. The facility failed to implement interventions to address Resident #1 and Resident #2's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +GP147922,70M233,ALF,7/16/2014,"Reported Perpetrator 2 (RP2) accepted a check in the amount of $6,923.47 from Resident #1 to pay off his/her car. RP2 also received $600 cash from Resident #1. RP2 quit and his/her whereabouts are unknown. RP2 was found responsible for financial exploitation which constitutes abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",4,,Not Substantiated,Substantiated,Financial abuse +GP150791,70M233,ALF,4/3/2015,The facility failed to provide a medication administration system that prevents theft or misuse of medications. A discrepancy of Resident #1's liquid pain medication was found. Some incidents of medication discrepancies were not reported or investigated promptly. The failure is a violation of Oregon Administrative Rules.,2,,,, +MF105816,70M234,ALF,12/1/2010,"The facility failed to conduct an RN assessment and intervene after Resident #1 expressed not feeling well for several days resulting in Resident #1 experiencing ongoing pain and suffering. Resident #1 was later diagnosed with pneumonia. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +MS116931,70M234,ALF,5/9/2011,"The facility failed to address and intervene after Resident #2 continued to make racial and derogatory comments and actions towards Resident #1. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,0,,,Neglect +MS117310,70M234,ALF,6/24/2011,"The facility failed to provide necessary household services resulting in poor hygiene and strong urine odor coming from Resident #1's room. Resident #1 has been observed on multiple occasions, incontinent. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +MS117516,70M234,ALF,7/21/2011,"Resident #1 had a history of strokes and experienced them on two consecutive days. 911 was not called after symptoms were observed. The facility failed to adequately care plan for Resident #1's strokes resulting in the potential for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS117312A,70M234,ALF,6/24/2011,"The facility failed to have Resident #1's pain medication available resulting in unrelieved pain that required transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,600,,,Neglect +MS117312B,70M234,ALF,6/24/2011,"The facility failed to provide a system that prevents theft or misuse of medications. Over 40 of Resident #1's narcotic medications were unaccounted for. Narcotic book and front and back of Resident #1's Medication Administration record were not consistent. The failure is a violaiton of resident rights, is considered financial exploitation and constitutes abuse.",3,0,,,Financial abuse +MS117312C,70M234,ALF,6/24/2011,"The facility failed to provide appropriate housekeeping resulting in poor continuity of care. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS117315A,70M234,ALF,6/20/2011,The facility failed to follow catheter care and positioning as directed resulting in urine backflow and posed a risk for infection. The failure is a violation of OARs.,2,0,,, +MS117315B,70M234,ALF,6/20/2011,"Staff were directed and failed to conduct one hour checks and notify medical professional of Resident #1's vitals including CBGs. The facility failed to assure Resident #1 was safe and adequately monitor as directed by Home Health and the resident_x001A_s service plan. Resident #1 was found deceased. The facility's failures are violation of resident rights, considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS117315C,70M234,ALF,6/20/2011,"The facility received Resident #1's topical cream and misplaced it. The facility failed to administer topical cream as ordered resulting in unreasonable discomfort the Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS117315D,70M234,ALF,6/20/2011,"The facility failed to conduct wound treatment as ordered resulting in worsening. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS117315E,70M234,ALF,6/20/2011,"The facility failed to care plan for falls resulting in a large skin tear to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,, +MS117393,70M234,ALF,7/6/2011,"Resident #1 and Resident #2 have had a history of aggressive behavior towards each other. The facility failed to appropriately address residents' behaviors resulting in negative behavior affecting other residents. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",2,250,,,Neglect +MS117538A,70M234,ALF,7/18/2011,The facility failed to have Resident #1's medication available resulting in the potential for harm. Resident #1's physician notified the facility of an antibiotic order to be picked up at the pharmacy but failed to do so. The failure is a violation of OARs.,2,0,,, +MS117538B,70M234,ALF,7/18/2011,The facility administers Resident #1's medication. The facility failed to administer medication as ordered. Resident #1 self administered her/his antibiotics with the facility's knowledge resulting in the resident taking more than the prescribed dose. The failure is a violation of OARs. There was no observable negative outcome as a result of the failure.,2,0,,, +MS117538C,70M234,ALF,7/18/2011,The facility failed to ensure the RN conducted daily checks on Resident #1's lungs as service planned resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +MS117538D,70M234,ALF,7/18/2011,The facility failed to notify Resident #1's physician when her/his blood sugar reading was above 300 on 15 separate occasions in the month of July 2011 resulting in the potential for harm. The failure is a violation of OARs.,2,0,,, +MS117990,70M234,ALF,3/19/2011,"The facility failed to provide a safe medication administration system resulting in the loss of Resident #1's pain medication. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse.",2,0,,,Financial abuse +MS128978A,70M234,ALF,1/19/2012,"The facility failed to adequately care plan regarding Resident #1's required assistance with showers and peri-care. Resident #1 did not receive assistance as needed between April - December 2011. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS128978B,70M234,ALF,1/19/2012,"Resident #1 requires assistance with toileting and was identified as a fall risk. The facility failed to answer Resident #1's call light in a timely manner on several occassions requiring Resident #1 to toilet self. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +MS128978C,70M234,ALF,1/19/2012,The facility was responsible for ordering and administering medications and treatments to Resident #1. The facility failed to order multiple medications and/or treatments for Resident #1. Staff were documenting that they were administering medications/treatments when they were not. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS129506,70M234,ALF,3/15/2012,Resident #1 had a routine medication the facility was responsible to administer. The Facility was unable to administer the medication at the specific time due to incorrect dose supplied by the pharmacy. The facility did not ensure appropriate medication was received at the time of delivery resulting in the resident missing a dose of medication. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS117760,70M234,ALF,8/12/2011,"The facility manages medication administration for eight diabetic residents who required insulin injections. It was discovered on the morning of August 12, 2011, the facility ran out of needles and was unable to administer residents' their medications as ordered. The facility failed to provide a safe medication administration system resulting in the potential for harm to multiple residents. The failure is a violation of Oregon Administrative Rules. The Notification of Findings was completed at a later date due to the extended period of time between incident date and processing by the Department.",2,0,,, +MF129892,70M234,ALF,4/24/2012,Witness #4 discovered cash while washing Resident #1's clothing and contacted RP2 to count a total of $560. Witness #4 later found an additional $105 and gave it to RP2. RP2 later admitted to taking money and returned $80. The facility failed to provide a safe environment resulting in being financially exploited by RP2. The failure is a violation of Oregon Administrative Rules. RP2 was found responsible for financial exploitation and is considered abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MS133730,70M234,ALF,7/9/2013,In July 2013 Resident #1 had $100 stolen out of his/her wallet. An unknown individual was found to have taken the money which is financial exploitation and considered abuse. The facility failed to protect Resident #1 from loss of money. The failure is violation Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +MS135317,70M234,ALF,12/3/2013,"The facility faiiled to provide Resident #1 with one dose of his/her medication on the day he/she moved into the facility. Resident #1 did not suffer any ill effects from missing this dose. However, this failure is a violation of Oregon Administrative Rule.",2,,,, +MS145604B,70M234,ALF,12/31/2013,Resident #2 had a physician's order for daily medication to reduce excess fluid. Witness testimony and facility documentation revealed the medication was not properly transcribed on the Medication Administration Record. Resident did not receive the medication for over a month resulting in the potential for harm. The failure is a violation of Oregon Administrative Rule.,2,,,, +MS145604A,70M234,ALF,12/31/2013,"Resident #1 had a medication order for the administration of a pain patch every 72 hours. RP2 failed to administer Resident #1's routine medication resulting in increased, uncontrolled pain. RP2 was found responsible for neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +MS145988,70M234,ALF,1/25/2014,RP2 administered another resident's medication to Resident #1 resulting in transportation to the hospital. Resident #1 returned with orders to monitor blood pressure. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care and constitutes abuse.,2,300,Not Substantiated,Substantiated,Neglect +MS148464,70M234,ALF,9/10/2014,"Reported Perpetrator #2 (RP2) asked for help with assisting Resident #1 transfer into his/her bed. Other facility staff were not able to provide assistance, and the facility does not have assistive devices available. RP2 assisted Resident #1 by him/herself, and Resident #1 was bruised during this transfer. The facility failed to provide adequate transfer assistance services to Resident #1. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MF149326,70M234,ALF,11/21/2014,"The facility failed to adequately maintain a safe administration system. Resident #1 missed several days of pain medication due to the facility failing to fill his/her pain prescription timely. Resident #1 experienced increased pain symptoms while not on his/her pain medication. Resident #1 also missed several days of diuretic medication resulting in increased leg swelling and weeping. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,550,,,Neglect +MS149053,70M234,ALF,10/27/2014,"The facility failed to administer pain medication to Resident #1 as ordered. Resident #1 did not receive his/her pain medication from the facility for several days resulting in increased pain and feelings of sickness in Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS149358,70M234,ALF,11/25/2014,"The facility failed to implement adequate interventions to protect Resident #2 from inappropriate behavior by Resident #1. Resident #1 makes derogatory remarks to Resident #2 which leads to altercations between the two residents. This failure is a violation of resident's rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MS149267,70M234,ALF,11/18/2014,"The facility failed to follow Residents #1 and #2's care plan for frequent incontinence checks. Resident #1 and Resident #2 were left in soaked briefs as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS149536,70M234,ALF,12/10/2014,"The facility failed to adequately care plan for verbal altercations between Resident #1 and Resident #2. Resident #2 called Resident #1 a derogatory name causing Resident #1 emotional distress. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MF149669,70M234,ALF,12/24/2014,"The facility failed to administer Resident #1's pain medication as ordered. Facility staff short acting pain medication to Resident #1 instead of the long acting medication Resident #1 was prescribed. Resident #1 experienced increased pain symptoms when he/she missed doses of the long acting pain medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,400,,,Neglect +MS150146,70M234,ALF,2/5/2015,"The facility failed to administer multiple doses of medication to Resident #1. One of the doses missed was for Resident #1_x001A_s pain medication resulting in increased pain symptoms. This violation is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",3,400,,,Neglect +MS159952,70M234,ALF,1/12/2015,"The facility failed to administer several of Resident #1's medication as ordered for three days. Resident #1 experienced discomfort due to the delay. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,300,,,Neglect +MS150125A,70M234,ALF,2/4/2015,The facility failed to administer Resident #1's blood clotting medication. Resident #1 did not receive several doses of their medication. This failure is a violation of Oregon Administrative Rules.,2,,,, +MS150125B,70M234,ALF,2/4/2015,The facility failed to monitor Resident #1's blood pressure as orderd. This failure is a violation of Oregon Administrative Rules.,2,,,, +MS150354,70M234,ALF,2/24/2015,"The facility failed to adequately monitor Residents #1 and #2 for aggression towards each other. Resident #1 and Resident #2 got into an altercation, and Resident #2 sustained a skin tear. This failure is considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS150732,70M234,ALF,3/28/2015,"The facility failed to adequately monitor Residents #1 and #2. Both residents have a history of aggression towards each other, and the two of them got into another altercation. This failure is a violation of Oregon Administrative Rules.",2,,,, +MS150689,70M234,ALF,3/25/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MF151499,70M234,ALF,6/8/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS151797,70M234,ALF,7/2/2015,"The facility failed to adequately monitor Resident #2 in relation to her behavior of verbally abusing Resident #1. Resident #2 has verbally abused Resident #1 several times with no interventions implemented by the facility to stop Resident #1's behavior. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS151547A,70M234,ALF,6/10/2015,"The facility failed to adequately intervene to prevent Resident #1 from injuring others while operating his/her scooter indoors. Resident #1 had a history of multiple accidents with his/her scooter. Resident #1 ran their scooter in Resident #2 injuring them. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS151547B,70M234,ALF,6/10/2015,"Resident #1 had a history of inappropriate sexual behaviors. The facility failed to adequately implement interventions to reduce Resident #1's behaviors. Resident #1 touched Resident #3 inappropriately. This failure is a considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MS152847,70M234,ALF,9/17/2015,The facility failed to report suspected abuse. Resident #1 and Resident #3 alleged they were inappropriately touched by Resident #2. The facility did not report the alleged abuse. This failure is a violation of Oregon Administrative Rules.,2,,,, +MS154065,70M234,ALF,12/28/2015,"Resident #1 and Resident #2 had medication go missing from the facility. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MS153575B,70M234,ALF,11/16/2015,The facility failed to adequately follow Resident #1 medication treatment prescription. Resident #1 was to have his/her gauze changed every 30 minutes. Resident #1 went more than 60 minutes without a gauze change. This failure is a violation of Oregon Administrative Rules.,2,,,, +ST117550,70M236,ALF,7/20/2011,"The facility failed to administer medication as ordered resulting in infection developing and/or worsening. Resident #1 required medical treatment to resolve the infection The facility's failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,0,,,Neglect +ST117679,70M236,ALF,8/9/2011,"Resident #1 was an identified fall risk. The facility failed to adequately care plan resulting in Resident #1 lying on the floor for several hours with a broken arm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST118042,70M236,ALF,9/13/2011,The facility failed to ensure a safe medication administration system resulting in Resident #1 being administered another resident's medication. Resident #1 was not harmed as a result of the medication error.,2,0,,, +ST118036,70M236,ALF,9/19/2011,"Resident #1 was care planned for staff to notify Resident #1's family when she/he refuses bathing. Resident #1 refused bathing for a month and the facility did not contact family resulting in the resident not getting bathed for approximately a month. The facility failed to ensure care planned was followed resulting in inadequate hygiene. The failure is a violation of resident rights, is considred neglect of care and constitutes abuse. Investigation was unable to determine if lack of bathing resulted in medical condition developing/worsening.",2,0,,,Neglect +ST118128,70M236,ALF,9/30/2011,The facility failed to provide a safe environment resulting in the loss of residents' money. An unknown individual was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +ST118801,70M236,ALF,10/10/2011,"RP2 made an agreement with Resident #1 while RP2 was working at the facility to lease Resident #1's car. Resident #1_x001A_s Power of Attorney objected and the Facility failed to intervene. RP2 made one small payment to Resident #1 and then quit. Resident #1 is requesting the car back from RP2 with no luck. The facility failed to protect Resident #1 from financial exploitation. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. Both the individual and the facility are held responsible for abuse.",3,0,Substantiated,Substantiated,Financial abuse +ST118802,70M236,ALF,12/21/2011,The facility failed to provide a safe environment resulting in the loss of three residents' money from their respective rooms. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for financial abuse.,3,0,Not Substantiated,Substantiated,Financial abuse +ST118046,70M236,ALF,9/11/2011,"Resident #1 required full assist with mobility. On or about September 11, 2011, RP2 failed to follow protocol resulting in Resident #1 receiving a skin tear. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for abuse.",2,0,Not Substantiated,Substantiated,Neglect +ST120482,70M236,ALF,5/28/2012,Resident #1 reported missing a valuable piece of jewelry made by a family member. A book of stamps was also reported missing at the same time. The facility failed to provide a safe environment resulting in financial exploitation by an unknown individual. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for financial exploitation and constitutes abuse.,3,0,Not Substantiated,Substantiated,Financial abuse +ST121281,70M236,ALF,9/23/2012,"It was reported Resident #1 was missing her/his wallet and a locket valued at $8,000. Resident #2 also reported pain medications missing from her/his room. During the course of the investigation, it was determined that the wallet may have been lost or missing while out of the facility. The facility failed to provide a safe environment resulting in the loss of Resident #1's locket and Resident #2_x001A_s medications. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse. The facility's failure is a violation of Oregon Administrative rules.",3,0,Not Substantiated,Substantiated,Financial abuse +ST121389,70M236,ALF,9/28/2012,Resident #1 required staff to administer specific medication at regular intervals. The facility administered Resident #1's 8AM medication at 9:45 AM after it was pointed out it was not administered. The facility failed to administer medication in a timely manner resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ST121937,70M236,ALF,12/17/2012,"Resident #1 reported a bottle of pain pills missing from the locked drawer in her/his room. Resident #1 always locks her/his door and left the keys to the medication drawer in her/his room. All staff have keys to residents' rooms. The facility failed to ensure a safe environment resulting in the loss of Resident #1's medication. An unknown individual was held responsible for the theft, is considered financial exploitation and constitutes abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +ST132200,70M236,ALF,1/22/2013,Resident #1 reported items missing from his/her room at the facility while he/she was residing elsewhere due to health reasons. Resident #1_x001A_s room was supposed to be locked at all times. An unknown individual was found responsible for the loss of Resident #1_x001A_s property. The facility failed to provide a safe environment resulting in the loss of Resident #1_x001A_s property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Not Substantiated,Financial abuse +ST132623A,70M236,ALF,3/10/2013,"On or about March 10, 2013, Resident #1 reported jewelry and narcotics missing from her/his room. RP2 was suspected of the thefts, however investigation was unable to determine who was responsible. Jewelry was later discovered in a different part of Resident #1's apartment and was believed to have been put back by the person who took it. The facility failed to provide a safe environment resulting in the loss of Resident #1's property. The failure is a violation of Oregon Administrative Rules. An unknown individual was held responsible for financial exploitation and is considered abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +ST132623B,70M236,ALF,3/10/2013,Resident #1 observed RP2 mimicked her/his walking. Resident #1 was upset by RP2's actions. Witness testimony revealed RP2 has a language barrier that makes it hard for her/him to sometimes communicate effectively. The facility failed to ensure RP2 had sufficient communication and language skills resulting in loss of dignity to Resident #1. The failure is a violation of Oregon Administrative Rules.,2,0,,, +ST133037,70M236,ALF,4/4/2013,"Resident #1 had multiple orders for medications and moved to the facility on April 4, 2013. Resident #1 was not administered her/his medications until April 6, 2013 and experienced unreleived pain. The facility failed to provide a safe medication administration system. The failure is violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST133685,70M236,ALF,5/7/2013,Resident #1 and Resident #3 each discovered money missing from their respective rooms on different dates. Resident #2 reported missing binoculars and camera. All rooms have been searched by staff and were unable to locate the missing items. The facility failed to provide a safe environment resulting in the loss of residents' property. The failure is a violation of Oregon Administrative Rules. An unknown individual has been held responsible for abuse.,2,,Not Substantiated,Substantiated,Financial abuse +ST133515,70M236,ALF,5/18/2013,"Resident #1 reported the loss of $200 cash from her/his locked room. RP2 was observed going into rooms and looking through residents' belongings. RP2 has been suspected of other thefts and staff reported suspicious behavior. The facility did not monitor RP2's behavior. The facility failed to provide a safe environment resulting in the loss of Resident #1's money. The failure is a violation of resident rights, is considered financial exploitation and constitutes abuse. An unknown person was also found responsible for financial exploitation and is considered abuse.",3,400,Substantiated,Substantiated,Financial abuse +ST133727,70M236,ALF,6/29/2013,"Resident #1 had an order for anti-seizure medication twice daily. Resident #1 was admitted to the facility On or about June 28, 2013. Facility staff failed to administer Resident #1's medication the following evening and the resident experienced a seizure. The facility failed to provide a safe medication administration system resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,200,,,Neglect +ST134716,70M236,ALF,10/2/2013,"Two residents reported missing money from their respective rooms. No suspects were identified. The facility failed to provide a safe environment. An unknown person was held responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ST146804,70M236,ALF,3/24/2014,"The facility failed to assess and implement adequate interventions around Resident #1's incontinent care. Resident #1 suffered a rash for over a year, and a UTI with sepsis that required hospital care. These failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ST147719,70M236,ALF,5/11/2014,"Resident #1 had a history of eloping from the facility. The facility failed to adequately monitor Resident #1 and he/she was able to elope again on or around 05/01/2014. This failure is considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ST148965,70M236,ALF,9/18/2014,The facility failed to ensure Resident #1's pain medication prescription was filled in a timely manner. Resident #1 had to go without his/her prescribed pain medication while the Prescription was awaiting to be filled. The facility gave Resident #1 a different pain medication during this time. This failure is a violation of Oregon Administrative Rules.,2,,,, +ST149029,70M236,ALF,11/19/2014,"The facility failed to administer Resident #1_x001A_s PRN pain medication as ordered. Resident #1 went without his/her PRN pain medication for over 48 hours due to the facility failing to fill it timely. Resident #1 expressed additional pain symptoms while he/she went without this medication. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +ST147719A,70M236,ALF,5/11/2014,"Resident #1 had a history of eloping from the facility. The facility failed to adequately monitor Resident #1 and she/he was able to elope again on or around 05/01/2014. This failure is a considered neglect of care, constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ST151524,70M236,ALF,6/8/2015,"Resident #1 required assistance with showers, reminders and assistance with wearing compression stockings, and assistance with incontinence and room cleaning. The facility failed to perform these services to the extent outlined in Resident #1's service plan. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +ST152434,70M236,ALF,7/1/2015,"The facility failed to adequately follow Resident #1_x001A_s care plan in relation to wound care. Resident #1_x001A_s wound worsened significantly as a result. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,400,,,Neglect +OT117330,70M237,ALF,5/15/2011,Resident #1 had bruising of unknown origin on thigh area and the facility failed to notify local APS office. The failure is a violation of OARs.,2,0,,, +CO15163,70M237,ALF,8/18/2015,"The facility failed to ensure an RN assessed and documented findings for residents who experienced a significant change of condition. Resident #4 had a series of significant weight losses. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +PT116048,70M238,ALF,12/29/2010,"A resident of the Facility discovered that he/she was missing narcotic pain medication from his/her room, approximately 35 pills. A Facility staff member admitted to borrowing from the resident's medication supply, but claimed to have returned them. The Facility was not able to conclusively determine who was responsible for the missing medication. Following the incident the resident was provided with a lockable drawer in his/her room.",2,0,,,Financial abuse +PT120961,70M238,ALF,6/15/2012,Resident #1 had $150 cash and a valuable family heirloom ring missing from her/his room. The facility failed to provides a safe environment resulting in the loss of Resident #1's property. An unknown individual was held responsible for financial exploitation and is considered abuse.,3,0,Not Substantiated,Substantiated,Financial abuse +PT121663,70M238,ALF,10/30/2012,"Rotten fruit, old snacks and other miscellaneous food items were found in Resident #1_x001A_s room. There were also bugs present on some of the items. There are discrepancies between Resident #1_x001A_s CAPS assessment and his/her service plan regarding memory/orientation. The facility failed to provide Resident #1 with needed services and update his/her service plan regarding memory/orientation. The failures are a violation of Oregon Administrative Rules.",2,0,,, +PT148957,70M238,ALF,10/9/2014,Resident #3 used foul language to Resident #1 and called names to Resident #2. Resident #3 had history of verbal/physical aggression towards staff and had care planned interventions; however this was the first incident where he/she made inappropriate comments towards other residents. The facility failed to ensure to provide a safe environment.,2,,,, +PT149623,70M238,ALF,11/20/2014,"Resident #1 was incontinent of urine and often refused assistance with toileting, bathing and laundry. His/her room and body smelled strongly of urine. His/her care plan did not address his/her care needs. The facility failed to properly plan care to ensure adequate hygiene. The failure is a violation or resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +CO11004,70M239,ALF,1/11/2011,,0,0,,, +BC116558,70M239,ALF,3/3/2011,A Facility staff member failed to administer medications to three residents. The Facility was able to determine the missed administrations through an audit of the resident's medication records. None of the residents experienced a negative outcome as a result of the staff member's error.,1,0,,, +BC116640,70M239,ALF,3/22/2011,"A Facility staff member, Reported Perpetrator #2 (RP2) was involved in an altercation with a Facility resident which resulted in injury to the resident's hand. RP2's statements of how the altercation took place were inconsistent with the resident's injuries and it was determined the residents version of events better supported the outcome to the resident. The staff member was terminated following an investigation into the incident. RP2 is being found individually responsible for abuse.",2,0,Not Substantiated,Substantiated,Physical Abuse +BC117424,70M239,ALF,7/10/2011,"A resident of the Facility discovered a significant amount of his/her personal valuables went missing. Upon reporting to the Facility about the missing items, the Facility contacted law enforcement, but failed to conduct an investigation into the matter.",2,0,,,Financial abuse +BC117479,70M239,ALF,7/13/2011,"Resident #1 had seven falls in the facility between July 14, 2010 and July 13, 2011, with no changes to the care plan. Three of the falls resulted in Resident #1 being transported to the hospital. The RN_x001A_s fall risk assessment was not completed until July 11, 2011. The facility failed to update Resident #1_x001A_s care plan to address falls. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,300,,,Neglect +BC118696,70M239,ALF,11/21/2011,"Between 11/21/11 and 11/28/11, Resident #1 had his/her purse, wallet and cash stolen from his/her room; and Resident #2's secured drawer was forced open and cash was stolen. The thefts of personal property were actions of an unknown individual.",2,0,Not Substantiated,Substantiated,Financial abuse +BC118783,70M239,ALF,12/10/2011,"Resident #1 had three falls in the facility between December 7, 2011 and December 12, 2011. One fall was an injury fall requiring him/her to go to the hospital for stitches above the right eyebrow. Resident #1 is not care planned for falls. The facility failed to update Resident #1_x001A_s care plan to address falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +BC128919,70M239,ALF,1/5/2012,Three residents reported money missing from their locked drawer in their apartments. An unknown individual was determined to be responsible for the theft of money. The facility failed to provide a safe environment for residents resulting in loss of property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +BC147114,70M239,ALF,3/24/2014,"Over a four day period Resident #1 waited in excess of fifteen minutes for assistance on fifteen separate occasions. Resident #1 called for assistance to the restroom and did not receive a response so attempted to toilet him/herself. Resident #1 fell and broke his/her hip. The facility failed to timely respond to Resident #1's requests for assistance. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC153210,70M239,ALF,10/10/2015,Witness #1 reported that a check in the amount of $400.00 was taken from Resident #1's room and forged. The name on the check belonged to Reported Perpetrator 2's (RP2) spouse. RP2 confessed to taking and forging Resident #1's check. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +BC120592,70M240,ALF,6/9/2012,"Resident #1 did not get his/her medication as prescribed for three days, resulting in decreased energy. The facility failed to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,0,,, +BC145704,70M240,ALF,1/11/2014,"Resident #1 is care planned for one person assistance for transfers. Reported Perpetrator 2 (RP2) was helping Resident #1 with a transfer but was not in an appropriate position to do this properly. Resident #1 fell and received and injury requiring hospital care. Reported perpetrator 2 failed to utilize appropriate transfer techniques when assisting Resident #1. This failure is considered neglect of care and constitutes abuse. The facility failed ensure Resident #1 was transferred safely, and this if a violation of Oregon Administrative Rules.",3,,Not Substantiated,Substantiated,Neglect +BC146122,70M240,ALF,1/29/2014,"It was discovered Resident #1's narcotic medications were stitched with a non-narcotic medication. Resident #1 had chronic knee pain, which the pain had been worse than normal. The facility failed to provide a safe medication administration system that prevented theft or misuse of medications. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC149134,70M240,ALF,10/27/2014,"Resident #1 was administered half of his/her physician ordered antibiotic from 10/22/14 to 10/25/14, a total of 6 doses. The facility failed to ensure a safe medication system to administer medication as ordered. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC148913,70M240,ALF,9/27/2014,"The facility failed to provide timely medical treatment after Resident #1_x001A_s fall on 9/26/14 and after his/her complaints of pain. Resident #1 was transported to the hospital and diagnosed with a fractured femur and pelvis. Upon return from the hospital, orders stated for Resident #1 to stay in bed for three (3) days and non-weight-bearing. Resident #1 complained of pain after using the bedside commode on 10/1/14 and 10/3/14. The facility failed to assess Resident #1 upon return from the hospital and failed to update his/her service plan. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +BC149495,70M240,ALF,12/4/2014,Resident #1 had medications stolen from his/her room. He/she self manages medications and kept medications in his/her room. The locking cabinet in his/her room was not accessible to Resident #1. An unknown person is responsible for the theft of medications. The facility failed to ensure an accessible locking cabinet to protect Resident #1 from theft.,2,,Not Substantiated,Substantiated,Financial abuse +BC153290,70M240,ALF,10/18/2015,Reported Perpetrator 2 (RP2) administered Resident #1 another residents_x001A_ medication and he/she was transported to the hospital for evaluation due to low blood pressure and returned shortly after. RP2's actions are considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system and violates Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Neglect +RD120485,70M241,ALF,5/24/2012,"Resident #1, Resident #2 and Resident #3 had a prescription for PRN narcotic medications; were cognitively intact, social, and alert; and aware of their medication administration. According to facility records, Reported Perpetrator 2 documented giving PRN medications to Resident #1, Resident #2 and Resident #3; however other staff administered much less in the same time period and the residents deny needing as many as documented. Preponderance of evidence suggests that Reported Perpetrator 2 misappropriated narcotic medications belonging to Resident #1, Resident #2 and Resident #3 and constitutes financial exploitation. The facility failed to provide a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +RD121997,70M241,ALF,12/6/2012,Resident #1 discovered money missing from his/her room. An unknown individual is responsible for the theft of money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +RD132974,70M241,ALF,4/5/2013,"It was reported Resident #1 loaned money to Reported Perpetrator 2 (RP2), which RP2 stated he/she received and did not pay back. RP2 stated he/she knew there was a facility policy against staff taking money from residents prior to accepting the money from Resident #1. RP2 was found responsible for abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +CO13131,70M241,ALF,9/12/2013,"The Facility failed to ensure Resident #3_x001A_s service plan were reflective of his/her recurring wounds; failed to ensure an RN assessed Resident #3 who experienced a significant change of condition related to weight loss and wounds; and failed to coordinate care with on-site providers for Resident #3 who received home health services. Resident #3 suffered recurring wounds and weight loss. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ES116900,70M242,ALF,5/2/2011,The facility failed to ensure Resident #1's Service Plan was followed. RP2 did not complete a 2 hour check on Resident #1 as service planned resulting in the potential for harm. Resident #1 indicated she/he was not harmed as a result of the failure.,2,0,,, +ES116933A,70M242,ALF,5/7/2011,The facility failed to provide a safe environment resulting in Resident #1 being transported to the hospital for treatment of a dislocated shoulder due to improper transfer by RP2 and RP3. The failure is a violation of resident rights is considered neglect of care and constitutes abuse. RP2 and RP3 were found responsible for abuse.,3,0,Not Substantiated,Substantiated,Neglect +ES118227,70M242,ALF,10/13/2011,"Resident #1 had a history of medical issues. Resident #1 reported not feeling well on October 11, 12 and 13, 2011. Resident #1 was found on the floor on October 14, 2011, and was transported to the emergency room for teatment and later admitted to the hospital. The facility failed to appropriately monitor Resident #1 for a change in condition. The failure is a violation of resident rights, is considered neglect and constitutes abuse.",3,300,,,Neglect +ES120384A,70M242,ALF,6/22/2012,Resident #1 reported his/her narcotic medications missing. The theft of narcotic medications resulted from the actions of an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES120293,70M242,ALF,6/8/2012,Resident #1 reported his/her medications missing. The theft of medications resulted from the actions of an unknown individual. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +ES121741,70M242,ALF,11/15/2012,"Residents #1, #2 and #3 were all missing money from their rooms. Reported Perpetrator 2 (RP2) was assigned to work the hall that they reside in. RP2 was investigated and resigned. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +ES120437,70M242,ALF,6/30/2012,"Resident #1 reported narcotic medications missing from his/her room. He/she had been out to run errands and upon returning to his/her room, noticed the medication was missing. An unknown individual was responsible for the loss of Resident #1's medication. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES120516A,70M242,ALF,7/13/2012,"Reported Perpetrator 2 (RP2) diverted a significant amount of prescription pain medications from Resident #2, #3, #4 and #5. RP2 would document that he/she had dispensed medications to residents when he/she had not. RP2 was found responsible for theft of narcotics which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Financial abuse +ES120516B,70M242,ALF,7/13/2012,"Resident #1 was prescribed pain medication to be dispensed once every six hours for pain. Reported Perpetrator 2 (RP2) fraudulently documented that he/she dispensed pain medication to Resident #1 at 3:30 AM. As a result, Resident #1 was unable to receive pain medication until 9:30 AM causing Resident #1 pain. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +ES133615,70M242,ALF,6/22/2013,Resident #1 and Resident #2 reported a large sum of cash missing from the lockbox in their room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES146757,70M242,ALF,4/14/2014,Resident #1 reported $500.00 missing from locking drawer in his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES146811,70M242,ALF,3/10/2014,Resident #1 reported money missing from his/her room. A camera was set up in Resident #1's room and captured Reported Perpetrator 2 (RP2) stealing from Resident #1's handbag. RP2 was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,300,Not Substantiated,Substantiated,Financial abuse +ES147079,70M242,ALF,4/30/2014,Resident #1 was given $50 by a family member and it was discovered missing four days later. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES134880,70M242,ALF,6/29/2013,Resident #1 and Resident #2 reported $30.00 in coins missing from their room. Resident #3 reported $100.00 missing from a wallet that had been in his/her locking drawer. Resident #4 reported $75.00 missing from his/her room. An unknown individual was determined to be responsible for the loss of residents' money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +ES149504,70M242,ALF,12/5/2014,"Resident #1 reported $40.00, a $50.00 TJ Maxx gift card and a necklace missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +ES153090,70M242,ALF,9/11/2015,Resident #1 was administered another resident's medication. Resident #1 did not suffer any negative outcome. The facility failed to provide a safe medication administration system. The facility also failed to report incident to APS. The failures are a violation of Oregon Administrative Rules.,2,,,, +HB116158A,70M243,ALF,1/19/2011,Resident #1 pulled the call light and his/her neck pendant after he/she fell; however it took approximately 15 minutes for staff to respond to provide assistance.,2,0,,, +HB116158B,70M243,ALF,1/19/2011,Resident #1 requested PRN pain medication; however staff were untimely in administering it to him/her and failed to initial the Medication Administration Record as having administered the medication.,2,0,,, +HB117165,70M243,ALF,6/5/2011,"Resident #1 was left outside at his/her wishes after returning from an outing; however communication breakdown occurred among staff and he/she was found disoriented about 50 yards away from the facility under the facility bus. Resident #1 was sweating, shaking, hallucinating and experienced incontinence.",2,0,,,Neglect +HB117423,70M243,ALF,7/11/2011,RP2 documented to administered narcotic medications to residents when she/he did not. The facility failed to provide a system that prevents theft or misuse of medications. RP2 was apportioned abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +HB118809A,70M243,ALF,12/27/2011,Resident #1 was cognitive and managed his/her own money. He/she reported money missing from his/her wallet. The investigation determined an unknown individual was responsible for the theft of money. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB128953A,70M243,ALF,1/9/2012,"On 1/9/12, Reported Perpetrator 2 (a facility staff member) was disoriented administering medications to residents; and later passed out and was taken by ambulance to the hospital. There were no observable negative outcomes to the residents; however residents were exposed to potential for harm. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,0,,, +HB128953B,70M243,ALF,1/9/2012,"On 1/9/12, Reported Perpetrator 2 (a facility staff member) was disoriented administering medications to residents; and later passed out and was taken by ambulance to the hospital. RP2 was found to have an excess of narcotic pain medication in his/her system, stated it was from an old personal prescription, and denied taking medications from residents. The internal investigation discovered multiple places where RP2 signed out the narcotic pain medications but no corresponding initials on the residents_x001A_ Medication Administration Record records. The facility failed to provide a safe medication system, exposing residents to potential harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +CO13050,70M243,ALF,4/25/2013,Order Imposing License Condition #ALFCD13-004 issued 5/10/2013 due to noncompliance.,3,0,,,Neglect +HB121318,70M243,ALF,10/11/2012,"Resident #1's medications were to be administered by facility staff. There were medications administered to Resident #1 that did not have orders in the Medication Administration Record (MAR), there were orders for medication that did not appear on Resident #1's MAR and Resident #1 did not receive ordered medication as prescribed. There was no apparent negative outcome to Resident #1. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB132350,70M243,ALF,2/3/2013,"The Facility failed to follow Resident #1's care plan and monitor him/her every two hours. Resident #1 was found on the floor and was transported to the hospital for treatment. He/she was on the floor for a number of hours and suffered unreasonable discomfort. The facility failed to provide facility records at the time of the investigation. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +HB133537A,70M243,ALF,6/18/2013,"Resident #1 was not administered his/her medication on 4/6/13 and 4/7/13. On 6/17/13, Reported Perpetrator 2 (RP2) administered Resident #1 another residents' medication; then his/her physician was notified and Resident #1 was placed on alert charting. The facility did not self report these incidents. The facility failed to report and failed to provide a safe medication administration system and the failures are a violation of Oregon Administrative Services.",2,,,, +HB133537B,70M243,ALF,6/18/2013,"The facility failed to care plan for and provide toenail care service to Resident #1 who had a diagnosis that required attention to toenail care, and failed to monitor his/her condition. Resident #1's toenails were thickened with yellowish discoloration; nail borders were incurvated; all toenails required extensive debridement and the big toenail on left foot was removed. The facilities failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB134985,70M243,ALF,11/7/2013,"Resident #1 self-administered his/her medications and began noticing pills were missing. Reported Perpetrator 2 (RP2) stole at least 4 pills from Resident #1, and RP2 confessed to the theft. RP2 is found responsible for the theft of Resident #1's medications and constitutes abuse. The facility failed to provide a safe environment and the failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB146094,70M243,ALF,2/18/2014,"Resident #1 was administered medications belonging to another resident with the same name. He/she was taken to the hospital and determined he/she did not suffer a negative outcome. The facility failed to provide a safe medication administration system, particularly that of same named residents. The failure is a violation of Oregon Administrative Rules.",2,,,, +HB147825,70M243,ALF,7/21/2014,Resident #1_x001A_s medications were reported missing when he/she returned from being out of the facility for 3 months due to a medical condition. The missing medication is a controlled substance. It was determined that an unknown individual is responsible for the theft of medications which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication system that prevented theft of medications. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +HB152608,70M243,ALF,8/26/2015,"Resident #1 had weak and brittle bones; had a medical condition that affects his/her memory, cognition and mood; and had a history of falls and impaired gait. The facility failed to adequately care plan for Resident #1_x001A_s fall risk to ensure safety. Resident #1 suffered a fall that resulting in a right wrist fracture, bruising on his/her left eye, left elbow, and left wrist. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB105652,70M245,ALF,11/8/2010,RP2 did not notify appropriate staff or document incident after Resident #1 was observed to have sustained injury from an unwitnessed fall. The facility failed to provide a safe environment resulting in the potential for harm to Resident #1.,2,0,,, +HB116741A,70M245,ALF,4/13/2011,RP2 roughly handled Resident #1's power chair causing pain and forced the resident back to her/his room without consent. RP2 was found substantiated for abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +HB116741B,70M245,ALF,4/13/2011,"On or about November 22, 2011, Resident #1 was found asleep in the dining room. RP3 took a spoon away from Resident #1 and was told to go to her/his room because the dining room was closed. The facility failed to assure Resident #1 was treated with dignity and respect and is a violation of OARs.",2,0,,, +HB116614,70M245,ALF,3/25/2011,Resident #1 had approximately $450.00 in his/her handbag. RV saw RP2 (Reported Perpetrator #2) getting into his/her handbag in his/her room. A few days later RV noticed money missing. It was determined that RP2 had taken Resident #1's money and he/she was detained by law enforcement.,2,0,,,Financial abuse +HB116687,70M245,ALF,4/7/2011,RP2 put inaccurate and inappropriate information into Resident #1's Care Plan causing the resident emotional harm. The facility failed to protect Resident #1 from emotional harm. RP2 was found responsible for abuse.,2,0,Not Substantiated,Substantiated,Verbal/Mental abuse +HB147541,70M245,ALF,6/26/2014,"Resident #1 was discovered with a large bruise of unknown origin and appropriately reported it. Witness testimony and facility documentation revealed Resident #1 was a known fall risk and experienced two recent falls, one of which may have contributed to the bruise. There was no documented follow up on the recent falls. The facility failed to appropriately monitor and respond after Resident #1 experienced two falls. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +HB148340,70M245,ALF,9/2/2014,"Resident #1 required assistance with ADL care including putting on and taking off her/his knee brace. Resident #1 was discovered with a wound that required antibiotic ointment on her/his right knee. It was discovered that Resident #1 was not receiving assistance with her/his knee brace, showers or dressing. The facility failed to ensure services were being met resulting in harm to Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB150126,70M245,ALF,2/4/2015,The facility failed to ensure a safe medication administration system resulting in Resident #1 not receiving a blood pressure medication for several weeks. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB150218,70M245,ALF,2/11/2015,"The facility failed to ensure a safe medication administration system resulting in harm to Resident #1 that required transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HB152409,70M245,ALF,8/10/2015,"Resident #1 fell and was unable to call for help because her/his call pendant was not working. On a separate occasion Resident #1 had to wait in her/his wheelchair for over an hour when the battery went out. The facility failed to ensure a safe environment resulting in unreasonable comfort for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +AL105768,70M247,ALF,9/16/2010,Resident #1 and Resident #2 discovered money missing from their wallets in their respective rooms. Resident #1 had a locking cabinet but was too full of other valuables and Resident #2 had a locking cabinet but did not have a key to lock it.,2,0,,,Financial abuse +AL116164,70M247,ALF,10/12/2010,"Resident #1 discovered money missing from his/her locked drawer that he/she kept locked with the key hidden in the apartment. The Facility_x001A_s failures are a violation of resident rights, are considered financial exploitation and constitute abuse.",2,250,,,Financial abuse +AL091564,70M247,ALF,3/7/2009,Resident #1 had additional pain medication added to his/her routine medications. He/she was administered a pain medication over the amount he/she was to receive.,2,0,,, +AL117751,70M247,ALF,3/1/2011,The Facility failed to follow Resident #1's care plan to document his/her shower tracking schedule and refusals.,1,0,,, +AL118775,70M247,ALF,10/16/2011,"On 10/16/11, Resident #2 became impatient waiting for Resident #1 to get seated in the dining room, and pushed Resident #1 out of his/her way onto his/her knees causing a small bruise. Resident #2 had no prior history of physical behaviors. The facility's dining room can become congested during mealtimes. The facility failed to implement procedures or increase staffing during mealtimes or activities in the congested dining room.",2,0,,, +AL120453B,70M247,ALF,3/19/2012,"Resident #1 was care planned requiring a two person transfer; however he/she was ""often"" not being transferred with two staff people. The facility failed to ensure Resident #1's care plan was followed. The failure is a violation of Oregon Administrative Rules.",2,0,,, +AL120557,70M247,ALF,3/29/2012,Resident #1 self administered an as needed narcotic pain medication. He/she did not keep the medications in the locked cabinet provided by the facility because it was unreachable due to his/her medical condition; and his/her apartment door was often left open or unlocked. It was determined an unknown person is responsible for Resident #1's loss of narcotic medication. The facility failed to provide a safe environment and an reachable locking cabinet. The failures are a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +CO13012,70M247,ALF,12/19/2012,"After an assisted fall to the floor on 9/16/2012, the facility failed to ensure Resident #2_x001A_s service plan was updated to reflect an increased need for assistance during transfers, specifically for two staff to be present for transfers. On 11/14/12, one staff person unsuccessfully attempted to transfer Resident #2 resulting in a femur fracture. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL133130,70M247,ALF,5/16/2011,"The facility failed to care plan appropriately and timely, and implement interventions regarding Resident #2_x001A_s behaviors. Resident #1 was affected by Resident #2_x001A_s behaviors. The failures are a violation of resident rights, are considered neglect of care resulting in sexual abuse and constitute abuse.",3,2500,,,Sexual abuse +AL145616,70M247,ALF,10/26/2013,"The facility failed to monitor and implement safety measures to provide a safe environment for Resident #1 who eloped from the facility, fell and suffered a fractured arm. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL146546,70M247,ALF,10/29/2013,"Beginning 9/26/13, the facility suspected Resident #1's behaviors were due to rapidly declining cognitive capacity. The facility failed to provide oversight and monitoring of his/her change of condition. On 10/29/13, Resident #1 hit Resident #2 multiple times in the face. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +AL148436,70M247,ALF,3/1/2014,"Resident #1 was found on the floor of his/her apartment after a fall resulting in a lumbar fracture. The facility failed to assess and intervene; to implement interventions; to increase monitoring; and to update his/her service plan regarding Resident #1's falls and decreased mental functioning and judgment. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +AL148821,70M247,ALF,3/9/2014,The facility failed to ensure Resident #1 was safe. He/she left the facility and was discovered to be at a local establishment. Resident #1 was gone from the facility for approximately 4 hours. The failure is a violation of resident rights and is a violation of Oregon Administrative Rules.,2,,,, +AL148994,70M247,ALF,3/18/2014,Resident #1 was care planned to be supervised when he/she wanted to go outdoors. Resident #1 was found by a citizen wandering an apartment complex and he/she was taken to the police station. The facility failed to follow Resident #1's care plan to ensure a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +AL151827,70M247,ALF,10/1/2014,"Resident #1 was not administered his/her seizure medication as ordered from 9/29/14 through 10/1/14, exposing him/her to harm. The facility failed to provide a safe medication administration system to ensure Resident #1 received his/her medications as ordered. The failure is a violation of resident rights and violates Oregon Administrative Rules.",2,,,, +AL152109,70M247,ALF,11/18/2014,Resident #1 was not administered his/her medication as ordered. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.,2,,,, +AL152299,70M247,ALF,11/12/2014,Resident #1 was not administered his/her vitamin supplement as ordered. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.,2,,,, +AL151940,70M247,ALF,1/21/2015,"On 1/23/15, Resident #1's physician faxed an order for home health; however it wasn't found until 1/30/15 and home health started 2/1/15. The facility failed to assure timely medical treatment. The failure is a violation of resident rights and violates Oregon Administrative Rules.",2,,,, +HM116497,70M248,ALF,2/24/2011,"Resident #1 had documented aggressive behaviors beginning September 2009 and was care planned for staff to remind him/her of inappropriate behavior; however he/she continued with aggressive behavior. The facility requested a medication review and his/her physician made a medication change on 3/9/11, and additional interventions were put in place. The facility failed to timely assess and intervene Resident #1's behaviors over the course of approximately one and half years.",2,0,,, +HM120246,70M248,ALF,6/1/2012,"Resident #1's medication was incorrectly transcribed on 5/31/12 resulting in an incorrect dose administered to him/her on 6/1/12. He/she became difficult to arouse from sleep. Resident #1 required an emergency response team to administer a quickly absorbed medication. The facility failed to provide an accurate Medication Administration Record for Resident #1 resulting in an unsafe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HM133335,70M248,ALF,5/7/2013,"Resident #2's Care Plan states he/she will be monitored during activities. During an activity in the dining room, there was an altercation when Resident #1 reacted to Resident #2, resulting in Resident #2 being hit on the hand with a spoon by Resident #1. Facility staff failed to follow Resident #2's Care Plan. The failure is a violation of Oregon Administrative Rules.",2,0,,, +HM150910,70M248,ALF,2/4/2015,"The facility failed to protect Resident #1 and Resident #2 from unwanted physical contact from Resident #3. Resident #3 had a history of touching residents, and touched Resident #1 and Resident #2. This failure is a violation of Oregon Administrative Rules.",2,,,, +HM151883,70M248,ALF,6/13/2015,"Resident #1 is independent in ambulation and transfers. Reported Perpetrator #2 continued to attempt to assist Resident #1 with a transfer and grabbed Resident #1s arms. Resident #1 did not want help, and resisted RP2. Resident #1 sustained bruising to his/her arm. RP2 is responsible for neglect of care, which constitutes abuse. The facility failed to provide a safe environment for Resident #1 which is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Neglect +HM152010,70M248,ALF,5/6/2015,"The facility failed to adequately update Resident #1_x001A_s service plan indicating he/she required two person assistance for transfers. The facility also failed to employ sufficient staff to ensure two care providers would be available to provide two person assistance to Resident #1. Reported Perpetrator #2 (RP2) attempted to transfer Resident #1 by themselves as the other care provider available was busy. Resident #1 sustained hip fracture during the transfer. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +HM153182,70M248,ALF,8/22/2015,"The facility failed to adequately ensure Reported Perpetrator #2 provided care. Several residents were left without toileting assistance, or had to wait extended periods for RP2 to answer their call lights. This failure is a violation of Oregon Administrative Rules.",2,,,, +MM105781,70M250,ALF,12/1/2010,"The facility failed to provide a safe medication administration system resulting in Resident #1 experiencing pain from not receiving medication as ordered and a two month delay in testing for Resident #2. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,0,,,Neglect +MM105908,70M250,ALF,10/25/2010,"The facility failed to adequately care plan related to falls resulting in the resident experiencing multiple falls with injuries that required transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM117478,70M250,ALF,7/12/2011,"The facility failed to provide a safe medication administration system resulting in Resident #1 being transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM129301,70M250,ALF,1/24/2012,Two staff members heard RP2 say she/he slapped Resident #1 after the resident slapped RP2. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules. RP2 was held responsible for physical abuse.,2,0,Not Substantiated,Substantiated,Physical Abuse +MM129840,70M250,ALF,4/12/2012,"Resident #1 was admitted to the facility on or about April 6, 2012 with known breathing problems. Resident #1 had regular and as needed medication to assist with breathing. Resident #1 was regularly observed having difficultly breathing, but facility staff failed to monitor or intervene. On April 15, 2012, Resident #1 stopped breathing and was admitted to the Intensive Care Unit at the hospital for approximately one week. The facility failed to monitor and intervene resulting in transportation to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM120147,70M250,ALF,5/24/2012,"Resident #1 had a history of back pain and had regularly scheduled pain medication. Resident #1 ran out of pain medication between May 17 and 24, 2012 resulting in unrelieved pain. The facility failed to provide a safe medication administration system resulting in pain and suffering. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM120360,70M250,ALF,6/18/2012,"The facility failed to provide a safe medication administration system to Resident #1 resulting in failure to ensure the resident received medication as ordered. Resident did not receive her/his routine morphine medication timely and failed to have other medication available. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,300,,,Neglect +MM120361,70M250,ALF,6/19/2012,"Resident #1 was service planned for assistance with showers and laundry needs. The facility failed to add Resident #1 to the shower and laundry schedules resulting in several weeks without a shower/bath and laundry service. Resident #1 developed a severe, painful rash and skin breakdown. The facility failed to follow Resident #1's service plan resulting in harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MM132423,70M250,ALF,2/14/2013,Resident #1 requires assistance with toileting and transfers. The facility failed to answer Resident #1's call light in a timely manner on multiple occassions resulting in the potential for harm. The facility also failed to appropriately investigate an incident of potential abuse. The failures are violations of Oregon Administrative Rules.,2,0,,, +MM132716,70M250,ALF,3/19/2013,"Home Health instructed Resident #1 to float heels off the bed in early March due to blister. There was no mention in Resident #1's service plan that Resident #1 was receiving Home Health services. The facility failed to assess Resident #1 for confusion and did not timely update service plan for the blister and confusion or direct staff on how to provide services. + +The failures are a violation of Oregon Administrative Rules.",2,,,, +MM121405,70M250,ALF,10/23/2012,Resident #1 requested assistance with putting sheets back on the bed after being laundered multiple times. Staff failed to respond to the request until after Resident #1 was in her/his recliner at 11 PM. Resident #1's care plan directed staff to remind resident of all meals. Investigator was with Resident #1 in her/his room until after 2 PM and no staff came in to remind the resident or provide a meal. The facility failed to follow care plan and requested services. The failures are violations of Oregon Administrative Rules.,2,,,, +MM146447,70M250,ALF,3/21/2014,Resident #1 requires assistance with toileting and transfers. The facility failed to answer Resident #1's call light in a timely manner resulting in the potential for harm. The facility also failed to have sufficient staff and is a potential for harm. The failures are violations of Oregon Administrative Rules.,2,,,, +MM147083,70M250,ALF,5/9/2014,"On or about May 2, 2014, Resident #1 was observed to be verbally abusive towards Resident #2. Witness testimony and facility documentation revealed Resident #1 had a history of verbally inappropriate behavior. Resident #1's service plan failed to provide staff direction on how to address the behavior. The facility failed to appropriately address Resident #1's behavior. The failure is a violation of Resident Rights, is considered neglect of care resulting in verbal abuse.",2,,,,Verbal/Mental abuse +MM148958,70M250,ALF,10/9/2014,"Resident #1 was admitted to the facility with a known history of sexually inappropriate behaviors. On or about October 9, 2014, Resident #1 exposed her/himself and made sexually inappropriate comments to staff and residents. The facility failed to ensure a safe environment resulting in loss of dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM148348,70M250,ALF,8/28/2014,"Resident #1 had an order for Ativan twice daily. On or about August 28, 2014 Resident #1 was transported to the hospital due to anxiety and suicidal ideation. Hospital test came back negative for benzoids which conflicted with facility medication records for administration. Resident #1 had no prior history of ""cheeking"" medication. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MM159764,70M250,ALF,1/1/2015,"Resident #1 had a history of unsafely wandering outside into traffic and care planned for staff to conduct one on one care when she/he attempted to leave. Starting at approximately 3:00 AM on January 1, 2015, Resident #1 expressed desire to leave the facility and was redirected by staff when observed going outside. At approximately 6:30 AM, Resident #1 wheeled self into traffic and was struck and killed. The facility failed to provide a safe environment and ensure the care plan was followed resulting in Resident #1's death. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",4,2500,,,Neglect +MM147203,70M250,ALF,5/21/2014,"Resident #1 experienced a significant change of condition with respect to behaviors and anxiety after witnessing a traumatic scene. The facility failed to appropriately care plan and monitor Resident #1's anxiety and behaviors. The facility also failed to appropriately address Resident #2's negative behavior affecting other residents. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +MM164441,70M250,ALF,1/6/2016,"RV1 obtains large sums of money from his/her local bank to pay his/her bills and for spending money. RV1 elects to keep the money in his/her room. RV1 has had several different episodes of money being lost at the facility or on the way home to the facility. Some of RV1's money was recovered but not all money has been recovered or accounted for. The money is presumed to be taken by an unknown individual and this individual is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility's failure to protect RV1's property from theft is a violation of the Oregon Administative Rules.",2,,Not Substantiated,Substantiated, +SV116302,70M251,ALF,1/31/2011,The facility failed to have an accurate medication administration record for Resident #1. The MAR indicated she/he received a specific medication when the facility was out of the medication. Witness testimony and facility documentation revealed difficulty in receiving the medication from the family in a timely manner. The failure is a violation of OARs.,2,0,,, +SV117633,70M251,ALF,8/2/2011,Multiple residents' narcotic medication bubble packs were discovered tampered with and replaced with other medications. Internal investigation was conducted and new system was put in place to prevent future incidents. An unknown individual was apportioned the abuse.,2,0,Not Substantiated,Substantiated,Financial abuse +MV120345,70M251,ALF,6/21/2012,"Staff reported two narcotic cards containing a total of 60 pills were missing during a routine narcotic count. Investigation was initiated and determined that the staff were not appropriately trained on following correct procedure for narcotic counts making it difficult to know the exact date and time the medications went missing. The facility failed to provide a safe medication administration system resulting in the loss of Resident #1's narcotic medications. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation and constitutes abuse. An unknown individual was also found responsible for financial exploitation and constitutes abuse.",2,0,Substantiated,Substantiated,Financial abuse +MV121747,70M251,ALF,11/7/2012,"Resident #1 was admitted to the facility on or about October 25, 2012 with orders including medication administration for a blood thinner. Facility documentation revealed Resident #1 did not receive her/his blood thinning medication and was transported to the hospital on two occasions. November 17, 2012 hospital visit revealed Resident #1 had a pulmonary embolism that was attributed to not receiving the ordered blood thinning medication. The facility failed to provide a safe medication administration system. The failure is violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV132461,70M251,ALF,10/25/2012,"Reported Perpetrator 2 (RP2) administered another resident's medication to Resident #1. Resident #1 became unresponsive and was transported to the hospital, treated and released back to the facility. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.",2,0,,, +WB145606,70M251,ALF,1/7/2014,"The facility ran out of pain medication for Resident #1 and as a result failed to administer medication as ordered for two days. Resident #1 exhibited additional pain symptoms as a result. This failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,, +WB146203,70M251,ALF,2/26/2014,"Resident #1 asked for ice cream, and facility staff believing they were out of ice cream attempted to give her a bowl of whip cream instead. When Resident #1 refused to eat the whip cream facility staff continued to try and get him/her to eat it. Resident #1 then became visibly upset and had to be escorted to his/her room to calm down. The facility failed to treat Resident #1 with dignity and respect. This failure is a violation of Resident Right's and Oregon Administrative Rules.",2,,,, +WB145924,70M251,ALF,1/17/2014,"The facility recently experienced a large amount of staff turnover, and switched to a knew pendant call system for its residents. The decreased staff and technical problems with the new call system caused the facility to fail to assist Resident #1 with toileting timely, resulting in him/her laying in urine. This failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.",2,,,,Neglect +WB147152,70M251,ALF,5/19/2014,"The facility failed to answer Resident #1's call light in a timely manner. Resident #1 was left incontinent for over an hour while waiting for assistance. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,250,,,Neglect +WB147153,70M251,ALF,5/12/2014,"The facility failed to reposition Resident #1 every two hours as indicated in his/her care plan. Resident # 1's decubitus ulcers worsened while at the facility. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +WB147154,70M251,ALF,5/12/2014,The facility failed to provide sufficient staffing in order to appropriately answer Resident #1's call light in a timely manner. Resident #1 had to wait 45 minutes for toileting assistance. This failure is a violation of Oregon Administrative Rules.,2,,,, +WB147749,70M251,ALF,7/1/2014,"The facility failed to adequaltely plan care in relation to cleaning Resident #1 when changing his/her depends. Resident #1 had a history of UTIs and developed another UTI at the facility. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MV147419,70M251,ALF,6/11/2014,"The facility failed to follow Resident #1's care plan and provide 4 times per shift toileting checks. Resident #1 was left in their own urine multiple times. This failure constitutes neglect of care, which is considered abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +MV148950,70M251,ALF,10/13/2014,Reported Perpetrator #2 (RP2) made inappropriate verbal comments to Resident #1. These verbal comments constitute verbal abuse. The facility failed to protect Resident #1 from inappropriate comments which is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Verbal/Mental abuse +MV148163,70M251,ALF,8/12/2014,The facility failed to adequately assist Resident #1 with toileting assistance in a timely manner. This failure is a violation or Oregon Administrative Rules.,2,,,, +MV148171,70M251,ALF,7/18/2014,The facility failed to provide Resident #1 with a dinner tray when he/she was too ill to attend dinner. This failure is a violation of Oregon Adminstrative Rules.,2,,,, +MV149238,70M251,ALF,11/12/2014,The facility failed to adequately provide cleaning services for Resident #1's room. Resident #1's apartment was found to be dirty with dried feces. This failure is a violation of Oregon Administrative Rules.,2,,,, +MV159979,70M251,ALF,1/5/2015,"The facility failed to administer Resident #1's insulin medication for over three months. Resident #1's diabetic symptoms worsened during this time. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MV159929,70M251,ALF,1/13/2015,The facility failed to administer Resident #1's medication as ordered. Resident #1 only received a half dose of medication when he/she was prescribed a full dose. This failure is a violation of Oregon Administrative Rules.,2,,,, +MV150931,70M251,ALF,4/9/2015,"The facility failed to adequately assess and intervene in relation to Resident #1_x001A_s falls. Resident #1had several falls and the facility did not update his/her care plan with interventions to reduce Resident #1_x001A_s fall risk. Resident #1 fell again and sustained a hip fracture. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,350,,,Neglect +MV151732,70M251,ALF,6/24/2015,"The facility failed to answer Resident #1's call light in a timely manner. Resident #1 was left on the toilet for 45 minutes and experienced pain and numbness in his/her legs. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,,Neglect +WB153420,70M251,ALF,11/2/2015,"Resident #1 had medication go missing from his/her room. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MV153691,70M251,ALF,11/12/2015,"Resident #1, Resident #2, and Resident #3 had medication go missing. The medication was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident 's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC146182,70M252,ALF,2/22/2014,"The facility failed to maintain an adequate medication administration system and provide Resident #1's pain medication as ordered. Resident #1 missed several doses of his/her pain medication as a result. These failures are a violation of resident rights, are considered neglect of care and constitute abuse.",3,300,,, +BC146280,70M252,ALF,3/5/2014,"The facility failed to administer Resident #1's pain medication as ordered on two separate days resulting in Resident #1 experiencing increased pain symptoms. These failures are a violation of resident rights, are considered neglect of care, and constitute abuse.",2,,,,Neglect +MF105284,70M253,ALF,9/20/2010,"Medications belonging to a resident of the Facility were found to be missing during a routine medication count. The Facility's system detected the theft, singled out staff members who had access and tested those staff members. Results of those tests concluded with the termination of a staff member.",1,0,,, +MS121506A,70M253,ALF,11/4/2012,Resident #1 punched Resident #2. Resident #2 sustained skin tears on his/her left arm and under his/her left eye. Both residents had previous instances of inappropriate behaviors. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS121506B,70M253,ALF,11/4/2012,A report was received that the facility failed to protect residents from inappropriate verbal comments. Residents were subjected to inappropriate verbal outbursts from Resident #1 and Resident #2. The facility failed to address Resident #1 and Resident #2_x001A_s behaviors. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS121476A,70M253,ALF,10/30/2012,Resident #1 and Resident #2 have a long history of incidents between them. Most recently they were involved in an altercation resulting in Resident #2 hitting Resident #1 in the stomach. The facility failed to address Resident #1 and Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,2,0,,, +MS121476B,70M253,ALF,10/30/2012,Resident #1 and Resident #2 were involved in multiple inappropriate verbal exchanges toward each other. The facility failed to address Resident #1 and Resident #2_x001A_s behavior. The failure is a violation of Oregon Administrative Rules.,0,0,,, +MF146657,70M253,ALF,4/4/2014,"Resident #1 reported narcotic medications missing from his/her room. He/she had a bottle delivered on 4/1/14 that contained one hundred tablets. As of 4/14/14, there were only thirty-three tablets left in the bottle. An unknown individual was found responsible for the theft of Resident #1's medication which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +MF149171,70M253,ALF,11/2/2014,"Resident #1 is physically impaired but able to make his/her own decisions. + +Reported Perpetrator 2 (RP2) was witnessed telling Resident #1 that he/she will go to bed when RP2 says to go to bed. RP2 also put Resident #1's call pendant out of reach. Witness #1 went directly into Resident #1's room and placed the pendant within reach. The facility failed to assure resident rights for Resident #1 and train staff appropriately. The failure is a violation of Oregon Administrative Rules.",2,,,, +MF148619,70M253,ALF,9/19/2014,Resident #1 and Resident #2 were involved in an altercation. No injuries were sustained. Resident #1 stated that Resident #2 had threatened him/her. Resident #2 denied allegation. Resident #2 had a history of being verbally aggressive and had been involved in other altercations. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,,, +MS150174A,70M253,ALF,2/8/2015,"Resident #1 was being transferred using a Transfer Disc. Resident #1's leg slipped and he/she was assisted to the floor slowly. Resident #1 sustained several bone fractures to his/her right leg, knee and hip. The facility failed to adequately update Resident #1's service plan to address fall interventions and transfers. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,300,,,Neglect +MS150174B,70M253,ALF,2/8/2015,"Resident #1 was being transferred using a Transfer Disc. Resident #1's leg slipped and he/she was assisted to the floor slowly. Resident #1 sustained several bone fractures to his/her right leg, knee and hip. Resident #1 was not transported to the hospital for four hours after the incident. The facility failed to assure timely medical treatment for Resident #1. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +MF150640,70M253,ALF,3/21/2015,"The facility failed to adequately monitor both Resident #1 and Resident #2. Both residents had a history of aggression towards each other and others. Resident #1 hit Resident #2 with his/her cane. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +GP128821,70M254,ALF,1/1/2012,"RP2 administered Resident #1 another resident_x001A_s medications resulting in being transported to the hospital for treatment. RP2 was being trained at the time of the incident and was administering medication unsupervised. The facility failed to provide a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. RP2 was not found responsible for abuse.",3,300,,,Neglect +GP120709,70M254,ALF,8/2/2012,"Resident #1 discovered around $200 cash missing from her/his wallet. Resident #1 did not leave the building much, always leaves money in the same spot and locks her/his door when not in the room. The facility failed to provide a safe environment resulting in the loss of money. The failure is a violation of Oregon Administrative Rules. An unknown individual was found responsible for financial exploitation and is considered abuse.",2,0,Not Substantiated,Substantiated,Financial abuse +GP118717,70M254,ALF,12/19/2011,"The facility failed to adequately care plan and provided needed services to Resident #1 resulting in toe nail infection and mold in nasal canula. The failures are violations of resident rights, are considered neglect of care and constitues abuse. The Notification of Findings was completed at a later date due to the extended period of time between the incident, investigation and processing by the Department.",2,0,,,Neglect +GP120674,70M254,ALF,7/31/2012,"Resident #1 had medication stolen. An unknown individual was found responsible for taking the medications and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +GP134961A,70M254,ALF,11/6/2013,"Resident #1 had post operation instructions for a amputated toe that included directions to not get the foot wet. An unknown staff member provided a shower to Resident #1 resulting in the foot getting wet and blood was observed. Resident #1 was taken to the hospital for treatment. The facility failed to ensure care instructions were followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. A civil penalty is warranted, however will not be issued due to a change of ownership on 8/29/14.",3,,,,Neglect +GP151834,70M254,ALF,7/7/2015,The facility failed to protect Resident #1 from inappropriate comments made by Reported Perpetrator #2. This failure is a violation of Oregon Administrative Rules.,2,,,, +GP151718,70M254,ALF,6/25/2015,"Residents #1 and #2 had money go missing from their room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +GP153270,70M254,ALF,10/26/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated, +GP153300,70M254,ALF,10/27/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,200,Not Substantiated,Substantiated,Financial abuse +GP150894,70M254,ALF,4/10/2015,"Resident #1 had money go missing from his/her room. The money was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +GP153845,70M254,ALF,11/1/2015,"The facility failed to administer Resident #1's pain medication as ordered. Resident #1 went several hours without his/her prescribed medication and experienced increased pain as a result. This failure is considered neglect of care, which constitutes abuse, and is a violation of Oregon Administrative Rules.",2,,,, +HB118260,70M255,ALF,9/11/2011,Resident #1 fell due to his/her wheelchair not being locked during an assisted transfer with a caregiver. No injuries sustained.,2,0,,, +HB129813,70M255,ALF,4/18/2012,Resident #1 and #2 reported money missing from their apartments. An unknown individual was responsible for the loss of money. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB132082X,70M255,ALF,1/8/2013,It was reported that Reported Perpetrator 2 (RP2) yelled and screamed at Resident #1 while helping him/her change their shirt making Resident #1 feel uncomfortable. The facility failed to assure resident rights. The failure is a violation of Oregon Administrative Rules,2,0,,, +HB121872X,70M255,ALF,12/7/2012,Resident #1 had earrings and money missing from his/her room. An unknown individual was responsible for the loss of Resident #1's property. The facility failed to provide a safe environment resulting in the loss of Resident #1's property. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Financial abuse +HB132790,70M255,ALF,3/23/2013,Reported Perpetrator 2 (RP2) yelled at Resident #1 during the course of a disagreement over medication administration. Resident #1 was upset by the incident. The facility failed to provide a safe environment by not assuring resident rights. The failures are a violation of Oregon Administrative Rules.,2,0,,, +HB133252,70M255,ALF,5/19/2013,Resident #1 reported money missing from his/her apartment. Facility security tapes were reviewed and Reported Perpetrator 2 (RP2) was identified entering Resident #1_x001A_s room. Resident #1 was away from the facility for five days. RP2 was arrested by law enforcement. RP2 was found responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +HB134115,70M255,ALF,8/14/2013,Resident #1 reported two rings missing from his/her room. An unknown individual was determined to be responsible for theft which constitutes financial exploitation. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Financial abuse +HB134535,70M255,ALF,9/26/2013,"Resident #1 had 2 rings go missing from his/her room. Reported Perpetrator #2 admitted to taking the rings and is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect Resident #1's property from theft. This failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +HB135255,70M255,ALF,11/27/2013,"Resident #1's service plan indicates two person assistance for transfers. Reported perpetrator 2 failed to follow the service plan and transferred Resident #1 into his/her assistive device by themselves. Resident #1 slipped out of his/her assistive device and Resident #1 helped him/her fall to the floor. Resident #1 did not sustain any injuries. The facility failed to ensure Reported Perpetrator 2 followed the service plan, which is a violation of Oregon Administrative Rules.",2,,,, +HB135492,70M255,ALF,12/26/2013,Resident #1 was prescribed a pain patch to be changed every 72 hours for chronic pain. Resident #1 expressed increased pain so the Medication Administration Record (MAR) was checked. Resident #1's pain patch was not changed the day before. A new patch was immediately applied. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +HB148976,70M255,ALF,10/16/2014,Resident #1 was being assisted to his/her room. Resident #1 tripped on the carpeting in the doorway of his/her room and fell. Resident #1 experienced soreness from the fall. A gait belt was not being used to assist Resident #1 although it was stated in Resident #1's service plan to do so. The facility failed to follow Resident #1's service plan regarding the use of a gait belt. The failure is a violation of Oregon Administrative Rules.,2,,,, +CO11108,70M256,ALF,7/29/2011,"The Facility failed to ensure investigations were complete and included appropriate follow up measures to incidents including reassessment, monitoring, or medication review for Resident #3. The Facility also failed to ensure investigations were complete or included appropriate responses to on going falls. The Facility failed to ensure the service plan was reflective of resident needs and preferences and updated after a significant change of condition for Resident #3. There was no information about the resident's history of falls, fall risk, failure to use the call light, measures to minimize the risk for further falls, or increased assistance needed due to the fractured ribs. The Facility failed to ensure residents were monitored consistent with their evaluated needs, and significant changes of condition were evaluated or referred to the RN with changes made to their evaluations and service plans for Residents #3 and #4. Resident #3 had multiple injury falls. Resident #4 had a severe weight loss. The Facility failed to ensure RN assessment was completed for Resident #3. The Facility failed to carry out orders as prescribed for Resident #3. Resident #3 experienced worsening of a skin tear. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,600,,,Neglect +JG118060,70M256,ALF,9/28/2010,RP2 inproperly delegated staff regarding injections to residents. The facility failed to ensure proper RN delegations were being conducted resulting in the potential for harm to residents. The failure is a violation of OARs. The Notification of Findings was completed at a later date due to the extended period of time between investigation and when it was processed by the Department.,2,0,,, +JG145619,70M256,ALF,11/17/2013,"Resident #1 was a new resident and staff were directed to check on every two hours. Resident #1 was discovered deceased at approximately 7:00 AM, foul play was ruled out and the cause of death is unknown. Witness testimony revealed Witness #5 last checked on the resident at 11:00 PM. The facility failed to ensure safety checks were implemented and is a violation of Oregon Administrative Rules. It is unable to be determined if the failure contributed to Resident#1's outcome.",2,,,, +JG135476,70M256,ALF,2/10/2013,"Resident #1 experienced multiple falls with injury. On two known occasions, new interventions were not implemented. There was a concern that Resident #1 was falling intentionally and a care conference was initiated to help resolve the ongoing falls. The facility failed to provide interventions on two occassions and is a violation of Oregon Administrative Rules.",2,,,, +JG146207,70M256,ALF,1/31/2014,"Resident #1 had a history of falls and care planned for frequent monitoring and offer assistance with needs. Resident #1 also has history of fragile skin. On or about January 30, 2014, Resident #1 was discovered with injury of unknown injury on left arm. Facility documentation revealed the facility failed to update Resident #1's care plan to address continued falls and fragile skin. The failures are a potential for harm and is a violation of Oregon Administrative Rules.",2,,,, +JG146205,70M256,ALF,2/15/2014,"Resident #1 required assistance with ADLs and care planned for toileting/incontinence care every two hours. On or about February 14, 2014, Resident #1 was discovered with an open wound. On three known occasions, Resident #1 was not provided incontinence care as care planned. Resident #1's wound worsened. The facility failed to ensure the care plan was followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +JG146889,70M256,ALF,4/1/2014,"Resident #1 experienced multiple falls with injury. Witness testimony and facility documentation revealed fall prevention measures were not implemented in a timely manner. Resident #1's care plan failed to address falls and provide staff direction. The failures are violation of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +JG134207,70M256,ALF,6/18/2013,"Complainant reported that the facility was notified RP2 took and was in possession of two residents' narcotic medications that were scheduled to be destroyed. Local law enforcement was notified and an internal investigation was initiated. Witness testimony and facility documentation confirmed the medications were taken. Further investigation revealed that the facility had an unsafe system for disposal of medications. The facility failed to ensure a safe medication administration system and is a violation of Oregon Administrative Rules. RP2 was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +JG147993,70M256,ALF,4/8/2014,"Resident #1 had a significant change of condition that required increased assistance with ambulation and toileting needs. Although the facility was providing care and services to address Resident #1's increased risk of falls, the facility failed to provide clear and specific direction on the delivery of services. The failure is a violation of Oregon Administrative Rules.",2,,,, +JG147994,70M256,ALF,4/22/2014,"Between the dates of April 12th and April 14th, 2014 multiple pills were found in the garbage can on RP2's medication cart. The pills discovered in the trash can belonged to RV2, RV3, RV4 and RV5. RP2 admitted to throwing away resident pills and not documenting resident MAR's appropriately. RV3 experienced an increase in anxiety during this time period. RP2's failure to dispense medications appropriately placed residents at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,Not Substantiated,Substantiated,Neglect +BH129783,70M257,ALF,3/31/2012,"Resident #1 has a medical condition related to memory loss and resided in a secure memory care facility. At approximately 4:00 PM, the resident was discovered missing. Resident #1 was located around 7:00 PM and was transported to the hospital for treatment. It was determined that the resident eloped through an unsecure area in the courtyard. The facility failed to provide a safe environment resulting in the resident being transported to the hospital for treatment. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",3,250,,,Neglect +BH150655,70M257,ALF,3/6/2015,"Resident #1's care plan directed for no male caregivers to provide bathing assistance. On or about March 6, 2015, RP2 provided shower assistance to Resident #1 as the resident did not get a shower from the previous shift. Witness statements did not reveal any negative outcome to the resident as a result. The facility failed to ensure the care plan was followed resulting in the potential for harm and is a violation of Oregon Administrative Rules.",2,,,, +ST134015,70M258,ALF,7/19/2013,"Resident #1 had money taken and Resident #2 reported food missing from their respective rooms. Facility failed to provide a safe environment resulting in the loss of resident property. The failure is a violation of Oregon Administrative Rules. RP2 was suspected, however investigation was unable to determine culpability. An unknown person was held responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ST146171,70M258,ALF,1/16/2014,"Resident #1 had known chronic pain with an order for scheduled and as needed liquid narcotic pain medication. Facility was notified of medication tampering and documentation revealed multiple discrepancies with the medication log book including diluting of the medication for several months. Documentation also showed Resident #1 continued to experience pain. Facility failed to report the medication tampering. The facility also failed to provide a safe medication administration and failed to provide a system that prevents theft or misuse of medication. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",3,300,,,Neglect +ST146743,70M258,ALF,3/17/2014,"RP2 was suspected of stealing medication and observed with hidden narcotic medications under medication cups. Review of the Medication Administration Records revealed multiple discrepancies with the Narcotic Log book. Witness testimony and facility documentation also revealed no auditing system was being conducted. The facility failed to provide a safe medication administration and failed to provide a system that prevents theft or misuse of medication resulting in the loss of medications from Resident #1 and Resident #2. The failures are violations of resident rights, are considered neglect of care resulting in financial exploitation and constitutes abuse. RP2 was also found responsible for financial exploitation and constitutes abuse.",3,350,Substantiated,Substantiated,Financial abuse +ST150372,70M258,ALF,2/25/2015,"The facility failed to ensure a safe medication administration system resulting in the loss of approximately 250 of Resident #1's narcotic medications. The failure is a violation of resident rights, is considered neglect resulting in financial exploitation and constitutes abuse.",3,350,,,Financial abuse +ST152056,70M258,ALF,4/21/2015,"Resident #1 had a history of aggressive behavior and care plan directs staff to escort from public areas when behaviors are disruptive. On or about April 21, 2015, Resident #1 threatened to hit Resident #2 with a chair because she/he would not get out of her/his chair. A visitor had to intervene to prevent a physical altercation. Resident #2 was negatively affected by the incident. The facility failed to appropriately monitor for Resident #1's behavior resulting in continued negative behavior affecting others. The failures are violations of resident rights, are considered neglect of care and constitutes abuse.",2,,,,Neglect +ST151744,70M258,ALF,4/7/2015,"The facility failed to ensure a safe medication administration system. The facility also failed appropriately monitor. Resident #1 experienced worsening of a rash. Investigative findings revealed Resident #1 was not administered the ordered medication as prescribed. The failures are violations of resident rights, are considered neglect of care and constitute abuse.",2,,,,Neglect +ST152907,70M258,ALF,9/22/2015,"Resident #1 discovered missing narcotic medication from her/his room. Resident #1's bank card was later discovered missing, however it is unclear if it was lost or stolen. The facility failed to ensure a safe environment resulting in the loss of Resident #1's medication and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +ST153319,70M258,ALF,6/15/2015,"Resident #1 and Resident #2 reported missing money from their rooms. The facility failed to report the incident and failed to conduct a timely investigation. The facility also failed to ensure a safe environment. The failures are violations of Oregon Administrative Rules. RP2 was named as a suspect, however no evidence supported that she/he was responsible. An unknown person was found responsible for theft of money, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +OR0001039305,70M258,ALF,12/14/2015,,0,,,Substantiated, +HB129799,70M313,ALF,2/28/2012,"Resident #1 had a history of falls. Resident #1 had a pressure alarm that was to be used on his/her bed. On February 28, 2012, Resident #1 fell sustaining a skin tear. The alarm did not function correctly. The facility failed to follow Resident #1_x001A_s care plan. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,0,,,Neglect +HB121018,70M313,ALF,9/9/2012,Reported Perpetrator 2 (RP2) went into Resident #1_x001A_s room to help him/her get ready and into bed. RP2 was joking around and gave Resident #1 a _x001A_purple nurple_x001A_ which is the twisting and pinching of a person_x001A_s nipples. Resident #1 was very upset over the incident. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.,2,0,Not Substantiated,Substantiated,Physical Abuse +HB147627,70M313,ALF,7/7/2014,Resident #1 was administered another resident's medication by RP2 resulting in transporation to the hospital for treatment. The facility failed to ensure Resident #1's medications were administered as ordered and is a violation of Oregon Administrative Rules. RP2 was found responsible for neglect of care and constitutes abuse.,3,,Substantiated,Substantiated,Neglect +HB148358,70M313,ALF,9/3/2014,"Resident #1 was transferred to the hospital after she/he was given another resident's medication. The facility failed to ensure a safe medication administration system. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +HB148927,70M313,ALF,10/15/2014,Resident #1 was identified as a known fall risk and was care planned to include matt on the floor while in bed. RP2 and RP3 failed to place the fall matt next to bed resulting in facial injury when the resident experienced a fall. The facility failed to ensure the care plan was followed and is a violation of Oregon Administrative Rules. RP2 and RP3 were found substantiated for neglect of care and constitutes abuse.,2,,Not Substantiated,Substantiated,Neglect +HB151152,70M313,ALF,5/4/2015,"Multiple residents reported missing money from their respective rooms. Local law enforcement was called, however no suspects were identified. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered neglect of care and constitutes abuse.",3,,Not Substantiated,Substantiated,Financial abuse +HB151493,70M313,ALF,6/8/2015,"The facility failed to ensure a safe environment resulting in the loss of Resident #1's narcotic medication from her/his room. The failure is a violation of Oregon Administrative Rules. An unknown person was found responsible for theft, is considered neglect of care and constitute abuse.",2,,Not Substantiated,Substantiated,Financial abuse +HB151777,70M313,ALF,7/1/2015,"Facility was notified that 70 narcotic pills were missing from her/his room. The facility failed to ensure a safe environment and is a violation of Oregon Administrative Rules. An unknown individual was found responsible for theft, is considered financial exploitation and constitutes abuse.",2,,Not Substantiated,Substantiated,Financial abuse +BC116607,7MU215,ALF,3/10/2011,Two residents of the Facility who were involved in a non-sexual relationship began having a sexual relationship. Resident #2 was assessed to have cognitive impairments to the degree that he/she was not able to make health related decisions. The Facility did not asses Resident #2's decision making ability with respect to his/her cognition and being in a sexual relationship.,2,0,,,Neglect +BC116733,7MU215,ALF,4/8/2011,"Facility staff failed to monitor Facility residents with respect to their service plans. Resident #1 and Resident #2 was not to be left unsupervised together, as the residents would become sexual towards each other. Resident #2 had previously been assessed as not able to consent to a sexual relationship, and staff was to make sure the resident was safe from such a relationship with other residents.",2,250,,,Neglect +BC116942,7MU215,ALF,5/5/2011,"A Facility staff member responded with inappropriate verbal comments when a resident was being rude to the staff member. The interaction was overheard by other staff and the staff member was counseled, however the staff member had already apologized to the resident and settled the issue.",1,0,,, +BC117042,7MU215,ALF,5/11/2011,The Facility failed to adequately assess and plan for Resident #1's outbursts of aggression towards other Facility residents and staff. Resident #1 became confrontational towards a staff member who was seated with another resident. Resident #1 suffered injury as a result of staff attempting to protect themselves from Resident #1. The Facility did not properly inform staff how to address these behaviors when and if they were to occur.,2,0,,,Neglect +BC117526,7MU215,ALF,7/1/2011,Resident #1's care plan instructed to change his/her clothes while in bed; however Reported Perpetrator 2 changed Resident #1's clothing while standing up. He/she fell and suffered a broken hip. Follow-up care plan indicated not to roll him/her on his/her side for incontinence care; however staff were seen positioning on his/her side while Resident #1 voiced pain. Staff failed to follow Resident #1's care plan.,3,0,Not Substantiated,Substantiated,Neglect +BC118471,7MU215,ALF,11/10/2011,"Resident #1 suffered bruising and skin tear injuries during the night of 11/9/11; and bandages were placed on his/her skin. When staff noticed his/her injuries at 7am on 11/10/11, there was no documentation in his/her chart regarding skin changes, as required to be reported to the nurse/doctor immediately.",2,0,,, +BC132697,7MU215,ALF,3/18/2013,"Reported Perpetrator 2 (RP2) was asked to administer medication to Resident #1. RP2 forcefully inserted a syringe into Resident #1_x001A_s mouth. The forceful insertion caused Resident #1 to panic, grimace and groan and clench his/her teeth. RP2 pulled the syringe out and left. RP2 said nothing to Resident #1. RP2 was found responsible for physical abuse. The facility failed to provide a safe environment. The failure is a violation of Oregon Administrative Rules.",2,0,Not Substantiated,Substantiated,Physical Abuse +BC133789,7MU215,ALF,7/10/2013,"Resident #1's Care Plan stated he/she visited an acquaintance regularly who lived a block from the facility and was able to return to the facility without assistance. Witnesses stated Resident #1 wandered around the neighborhood before, disoriented. The facility failed to properly care plan around Resident #1's tendency to leave the facility and become disoriented, exposing him/her to potential harm. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC133944,7MU215,ALF,7/27/2013,"Resident #1 was involved in three altercations with Resident #2 from 7/20/13 to 9/7/13. The facility failed to implement interventions to address Resident #1's behaviors. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.",2,,,,Neglect +BC134360A,7MU215,ALF,7/16/2013,"During May and June 2013, there were several incidents where Reported Perpetrator 2 (RP2) signed out PRN narcotics, but did not document in the electronic Medication Administration Record. The facility failed to keep the medication record current or accurate. The failure is a violation of Oregon Administrative Rules.",2,,,, +BC135443,7MU215,ALF,12/12/2013,"Between 9/8/13 and12/11/13, Reported Perpetrator 2 (RP2) admitted to taking Resident #1_x001A_s narcotic pain medication for a total of 71 incidences. RP2 was responsible for theft of Resident #1_x001A_s medications which constitutes financial exploitation. The facility failed to provide a medication administration system that prevents theft or misuse of medication. The failure is a violation of Oregon Administrative Rules.",2,,Not Substantiated,Substantiated,Financial abuse +BC134350,7MU215,ALF,8/31/2013,Resident #1 was being transferred without using a Hoyer lift. His/her care plan states that the Hoyer lift is to be used for all transfers. Resident #1's knees buckled and he/she was lowered to the floor. Resident #1 sustained a scrape and bruising. Staff had not been trained on using the Hoyer lift or incident reporting. The facility failed to follow Resident #1's care plan or assure staff received adequate training. The failures are a violation of Oregon Administrative Rules.,2,,,, +BC133876A,7MU215,ALF,7/25/2013,Multiple changes in Resident #1's medication created confusion. Three packets of unlabeled medication were left in Resident #1's room. Reported Perpetrator 2 (RP2) gave a non-employee two of Resident #1's narcotic medications to administer to Resident #1 for pain relief. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC133876B,7MU215,ALF,7/25/2013,Requests were made for help toileting and changing Resident #1. Requests were denied due to requested service not being on the service plan. The facility failed to provide service and assure staff were trained appropriately. The failures are a violation of Oregon Administrative Rules.,2,,,, +BC145910,7MU215,ALF,1/13/2014,Resident #1 has experienced multiple incidents regarding medication administration. The incidents included being offered medications belonging to another resident and late medication administration. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC146298,7MU215,ALF,3/5/2014,Resident #1 was administered another resident's medications. The error was discovered immediately and Resident #1 was transported to the hospital upon his/her physician's request for monitoring. He/she had no adverse effects from the medication error. The facility failed to provide a safe medication administration system. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC147934,7MU215,ALF,7/26/2014,Resident #1 had a diagnosis related to memory impairment and resided in an endorsed memory care facility. Resident #1 was observed with a open container of cleaning solution after RP2 left it on a table. RP3 did not timely follow up with poison control. There was no observable negative outcome as a result of the incident. The facility failed to ensure a safe environment resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules.,2,,,, +BC150787,7MU215,ALF,3/23/2015,RP2 hit Resident #1 on the head resulting in a negative outcome. RP2 was found responsible for physical abuse. The facility failed to ensure a safe environment resulting in harm to Resident #1 and is a violation of Oregon Administrative Rules.,2,,Not Substantiated,Substantiated,Physical Abuse +BC153068,7MU215,ALF,10/2/2015,"The facility failed to ensure adequate staff to meet resident care needs resulting in a fall with injury. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.",2,,,,Neglect +BC153713,7MU215,ALF,11/11/2015,"Resident #1 had a history of unstable blood sugars that required constant management and communication with physician. Investigative findings revealed on a few occasions, Physician's order was not followed as directed resulting in the potential for harm. The failure is a violation of Oregon Administrative Rules",2,,,, +BC164477,7MU215,ALF,1/26/2016,"On January 28, 2016 RV1 was administered a sleeping medication in error by RP2. RP2 realized his/her mistake, notified staff and RV1 was monitored throughout the night. The facility failed to administer medications as ordered. The facility's failure is a violation of the Oregon Administrative Rules.",2,,,, diff --git a/data/facilities.csv b/data/facilities.csv index e806392..163f76f 100644 --- a/data/facilities.csv +++ b/data/facilities.csv @@ -1,645 +1,645 @@ -facid,fac_type,capacity,fac_name,fac_address,city_state_zip,,owner,operator -385008,NF,96,Presbyterian Community Care Center,1085 N Oregon St,"Ontario, OR 97914",,"Presbyterian Nursing Home, Inc.","Presbyterian Nursing Home, Inc." -385010,NF,159,Laurelhurst Village Rehabilitation Center,3060 SE Stark St,"Portland, OR 97214",,"Laurelhurst Operations, LLC","Laurelhurst Operations, LLC" -385015,NF,128,Regency Gresham Nursing & Rehabilitation Center,5905 SE Powell Valley Rd,"Gresham, OR 97080",,"Regency Gresham Nursing & Rehabilitation Center, LLC","Regency Pacific Management, LLC" -385018,NF,98,Providence Benedictine Nursing Center,540 South Main St,"Mt. Angel, OR 97362",,Providence Health & Services - Oregon,Providence Health & Services - Oregon -385024,NF,91,Avamere Health Services of Rogue Valley,625 Stevens St,"Medford, OR 97504",,"Medford Operations, LLC","Medford Operations, LLC" -385031,NF,127,Avamere Crestview of Portland,6530 SW 30th Avenue,"Portland, OR 97239",,"Crestview Operations, LLC","Crestview Operations, LLC" -385039,NF,84,Baycrest Health Center,3959 Sheridan Ave,"North Bend, OR 97459",,"Bay Area Properties, LLC","Radiant Senior Living, Inc." -385044,NF,83,Prestige Care and Rehabilitation of Menlo Park,745 NE 122nd Ave,"Portland, OR 97230",,Care Center (Menlo Park) Inc.,"Prestige Care, Inc." -385045,NF,99,Porthaven Healthcare Center,5330 NE Prescott,"Portland, OR 97218",,Care Center (Porthaven) Inc.,"Prestige Care, Inc." -385046,NF,83,Hillside Heights Rehabilitation Center,1201 McLean Blvd,"Eugene, OR 97405",,Hillside Heights L.L.C.,"Pinnacle Healthcare Management, Inc." -385049,NF,90,Columbia Basin Care Facility,1015 Webber Rd,"The Dalles, OR 97058",,"Wasco County Nursing Care, Inc.","Aidan Health Services, Inc." -385053,NF,92,Avamere Rehabilitation of Eugene,2360 Chambers St,"Eugene, OR 97405",,"Eugene Rehabilitation, LLC.","Eugene Rehabilitation, LLC." -385055,NF,64,Prestige Care and Rehabilitation of Reedwood,3540 SE Francis St,"Portland, OR 97202",,Care Center (Reedwood) Inc.,Prestige Care Inc. -385064,NF,102,Regency Care of Rogue Valley,1710 NE Fairview Ave,"Grants Pass, OR 97526",,"BD Grants Pass I, LLC","Regency Pacific Management, LLC" -385068,NF,106,Village Health Care,3955 SE 182nd Ave,"Gresham, OR 97030",,"Village Health Care I, LLC","Village Health Care I, LLC" -385072,NF,135,Corvallis Manor Nursing & Rehabilitation Center,160 NE Conifer Blvd,"Corvallis, OR 97330",,"MCH Enterprises, Inc.","Pinnacle Healthcare Management, Inc." -385077,NF,136,Marquis Springfield,1333 N First,"Springfield, OR 97477",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385091,NF,87,Hearthstone Nursing and Rehabilitation Center,2901 E Barnett Rd,"Medford, OR 97504",,"Hearthstone Operator, LLC","Pinnacle Healthcare Management, Inc." -385104,NF,100,Hood River Care Center,729 Henderson Rd,"Hood River, OR 97031",,"Care Center (Hood River) Inc.,","Prestige Care, Inc." -385107,NF,67,Timberview Care Center,1023 6th Avenue Southwest,"Albany, OR 97321",,"PCI Care Venture I, Inc.","Prestige Care, Inc." -385112,NF,180,West Hills Health & Rehabilitation Center,5701 SW Multnomah Blvd,"Portland, OR 97219",,West Hills Convalescent Center Limited Partnership,West Hills Convalescent Center Limited Partnership -385115,NF,47,Lakeview Gardens LLC,700 South J,"Lakeview, OR 97630",,"Lakeview Gardens, LLC","Lakeview Gardens, LLC" -385117,NF,80,French Prairie Nursing and Rehabilitation Center,601 Evergreen Rd,"Woodburn, OR 97071",,"3C2MD, Inc.","Pinnacle Healthcare Management, Inc." -385120,NF,121,Valley West Health Care Center,2300 Warren St,"Eugene, OR 97405",,"Life Care Centers Of America, Inc.","Life Care Centers Of America, Inc." -385121,NF,100,Friendship Health Center,3320 SE Holgate Blvd,"Portland, OR 97202",,"Friendship Health Center, Inc.","Friendship Health Center, Inc." -385125,NF,95,Avamere Rehabilitation of Oregon City,1400 Division St,"Oregon City, OR 97045",,"Mountain View Rehab, LLC","Mountain View Rehab, LLC" -385126,NF,117,Avamere at Three Fountains,835 Crater Lake Ave,"Medford, OR 97504",,"Waterford Operations, LLC","Waterford Operations, LLC" -385132,NF,148,Avamere Rehabilitation of King City,16485 SW Pacific Hwy,"Tigard, OR 97224",,"King City Rehab, LLC","King City Rehab, LLC" -385133,NF,82,Good Samaritan Society - Fairlawn Village,3457 NE Division,"Gresham, OR 97030",,Evangelical Lutheran Good Sam. Society,Evangelical Lutheran Good Sam. Society -385136,NF,100,Glisan Care Center,9750 NE Glisan St,"Portland, OR 97220",,Care Center (Glisan) Inc.,"Prestige Care, Inc." -385137,NF,95,Marquis Plum Ridge,1401 Bryant Williams Dr,"Klamath Falls, OR 97601",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385138,NF,74,Pilot Butte Rehabilitation Center,1876 NE Hwy 20,"Bend, OR 97701",,"BD Bend II, LLC","Regency Pacific Management, LLC" -385141,NF,120,Marquis Mt Tabor,6040 SE Belmont,"Portland, OR 97215",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385142,NF,72,Regency Florence,1951 E 21St Street,"Florence, OR 97439",,"Regency Florence, LLC","Regency Pacific Management, LLC" -385143,NF,118,Umpqua Valley Nursing & Rehabilitation Center,525 W Umpqua St,"Roseburg, OR 97470",,"Umpqua Valley Nursing & Rehabilitation Center, LLC","Pinnacle Healthcare Management, Inc." -385144,NF,71,Clatsop Care Center,646 16th St,"Astoria, OR 97103",,Clatsop Care Center Health District,Clatsop Care Center Health District -385145,NF,88,Robison Jewish Health Center,6125 SW Boundary,"Portland, OR 97221",,Robison Jewish Home,Robison Jewish Home -385147,NF,87,Good Samaritan Society - Eugene Village,3500 Hilyard St,"Eugene, OR 97405",,The Evangelical Lutheran Good Samaritan,The Evangelical Lutheran Good Samaritan -385148,NF,145,Royale Gardens Health & Rehabilitation Center,2075 NW Highland Ave,"Grants Pass, OR 97526",,"RGO, LLC","Pinnacle Healthcare Management, Inc." -385149,NF,119,Highland House Nursing & Rehabilitation Center,2201 NW Highland Ave,"Grants Pass, OR 97526",,Highland House Inc.,"Pinnacle Healthcare Management, Inc." -385150,NF,92,Molalla Manor Care Center,301 Ridings Ave,"Molalla, OR 97038",,Care Center (Molalla) Inc.,"Prestige Care, Inc." -385151,NF,121,Rose Haven Nursing Center,740 NW Hill Place,"Roseburg, OR 97471",,"Fisher Care, Inc.","Pinnacle Healthcare Management, Inc." -385152,NF,80,Coast Fork Nursing Center,515 Grant St.,"Cottage Grove, OR 97424",,"Coast Fork Nursing Center, Inc.","Prestige Care, Inc." -385155,NF,114,Forest Grove Rehabilitation and Care Center,3900 Pacific Ave,"Forest Grove, OR 97116",,"PCI Care Venture I, Inc.","Prestige Care, Inc." -385156,NF,110,Green Valley Rehabilitation Health Center,1735 Adkins St,"Eugene, OR 97401",,Green Valley L.L.C.,"Pinnacle Healthcare Management, Inc." -385157,NF,114,Life Care Center Of Coos Bay,2890 Ocean Boulevard,"Coos Bay, OR 97420",,"Life Care Centers Of America, Inc.","Life Care Centers Of America, Inc." -385161,NF,129,Milton Freewater Health and Rehabilitation Center,120 Elzora St,"Milton-Freewater, OR 97862",,"Evergreen Oregon Healthcare Orchards Rehabilitation, L.L.C.","EmpRes Healthcare Management, LLC" -385162,NF,52,Avamere Rehabilitation of Newport,835 SW 11th,"Newport, OR 97365",,"Newport Rehabilitation, LLC.","Newport Rehabilitation, LLC." -385164,NF,29,Aidan Senior Living at Reedsport,600 Ranch Rd,"Reedsport, OR 97467",,"Aidan Senior Living at Reedsport, Inc","Aidan Senior Living at Reedsport, Inc" -385165,NF,59,Good Samaritan Society - Curry Village,1 Park Avenue,"Brookings, OR 97415",,The Evangelical Lutheran Good Samaritan,The Evangelical Lutheran Good Samaritan -385166,NF,165,Maryville Nursing Home,14645 SW Farmington Rd,"Beaverton, OR 97007",,Sisters of St. Mary of Oregon Maryville Corp.,Sisters of St. Mary of Oregon Maryville Corp. -385167,NF,110,South Hills Rehabilitation Center,1166 East 28th Ave,"Eugene, OR 97403",,"Garber Enterprises, Inc.","Pinnacle Healthcare Management, Inc." -385168,NF,84,Avamere Rehabilitation of Lebanon,350 S 8th St,"Lebanon, OR 97355",,"Lebanon Care Center, LLC","Lebanon Care Center, LLC" -385171,NF,110,Life Care Center Of McMinnville,1309 NE 27th St,"McMinnville, OR 97128",,"McMinnville Medical Investors , LLC ","Life Care Centers Of America, Inc." -385172,NF,83,The Dalles Health and Rehabilitation Center,1023 W 25th,"The Dalles, OR 97058",,"Evergreen Oregon Healthcare Valley Vista, L.L.C.","EmpRes Healthcare Management, LLC" -385180,NF,54,Marquis Newberg,441 Werth Blvd.,"Newberg, OR 97132",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385181,NF,20,"East Cascade Retirement Community, LLC",175 NE 16th St.,"Madras, OR 97741",,"East Cascade Retirement Community, LLC","Senior Housing Managers, LLC" -385182,NF,76,Creswell Health and Rehabilitation Center,735 South 2nd St,"Creswell, OR 97426",,Care Center (Laneco) Inc.,Prestige Care Inc. -385183,NF,80,Marquis Centennial Post Acute Rehab,725 SE 202nd Ave,"Portland, OR 97233",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -385185,NF,119,Avamere Riverpark of Eugene,425 Alexander Loop,"Eugene, OR 97401",,"Riverpark Operations, LLC","Riverpark Operations, LLC" -385187,NF,105,Cascade Terrace Nursing Center,5601 SE 122nd,"Portland, OR 97236",,Care Center (Cascade Terrace) Inc.,"Prestige Care, Inc." -385188,NF,80,Independence Health and Rehabilitation Center,1525 Monmouth St,"Independence, OR 97351",,Evergreen Oregon Healthcare Independence L.L.C.,"EmpRes Healthcare Management, LLC" -385189,NF,88,Avamere Transitional Care at Sunnyside,4515 Sunnyside Rd SE,"Salem, OR 97302",,"Sunnyside Operations, LLC","Sunnyside Operations, LLC" -385190,NF,78,Prestige Post-Acute and Rehabilitation Center-Gresham,405 NE 5th St,"Gresham, OR 97030",,Pacific Regency Care LLC,Prestige Care Inc. -385195,NF,104,Avamere Rehabilitation of Beaverton,11850 SW Allen Blvd,"Beaverton, OR 97005",,"Beaverton Rehab & Specialty Care, LLC","Beaverton Rehab & Specialty Care, LLC" -385197,NF,87,Linda Vista Nursing & Rehab Center,135 Maple St,"Ashland, OR 97520",,Care Center (Linda Vista) Inc.,"Prestige Care, Inc." -385199,NF,84,Chehalem Health & Rehab Center,1900 E Fulton St,"Newberg, OR 97132",,Care Center (Chehalem) Inc.,"Prestige Care, Inc." -385200,NF,6,Willamette View Health Center,13145 SE River Rd,"Milwaukie, OR 97222",,"Willamette View, Inc. dba","Willamette View, Inc." -385201,NF,59,Willowbrook Terrace,707 SW 37th Street,"Pendleton, OR 97801",,"Care Center (Willowbrook), Inc.","Prestige Care, Inc." -385203,NF,87,Avamere Rehabilitation of Clackamas,220 East Hereford,"Gladstone, OR 97027",,"Clackamas Rehabilitation , LLC.","Clackamas Rehabilitation, LLC." -385204,NF,63,Marquis Forest Grove Post Acute Rehab,3300 19th Avenue,"Forest Grove, OR 97116",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -385206,NF,95,Mennonite Home,5353 Columbus Street Southeast,"Albany, OR 97322",,"Mennonite Home Of Albany, Inc.","Mennonite Home Of Albany, Inc." -385207,NF,121,Dallas Retirement Village Health Center,377 NW Jasper Street,"Dallas, OR 97338",,"Dallas Health Care Center, LLC",Life Care Services LLC -385208,NF,70,Marquis Piedmont Post Acute Rehab,319 NE Russet,"Portland, OR 97211",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -385211,NF,76,LaGrande Post Acute Rehab,91 Aries Lane,"La Grande, OR 97850",,"Evergreen Oregon Healthcare Mt Vista, L.L.C.","EmpRes Healthcare Management, LLC" -385214,NF,54,Marquis Mill Park,1475 SE 100th Avenue,"Portland, OR 97216",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385217,NF,78,EmpRes Hillsboro Health and Rehabilitation Center,1778 NE Cornell Rd,"Hillsboro, OR 97124",,"Evergreen Oregon Healthcare Tualatin, L.L.C.","EmpRes Healthcare Management, LLC" -385218,NF,73,Marquis Vermont Hills,6010 SW Shattuck Rd,"Portland, OR 97221",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385219,NF,93,Care Center East Health & Specialty Care Center,11325 NE Weidler,"Portland, OR 97220",,FMG Northeast Weidler Street Oregon LLC,FMG Northeast Weidler Street Oregon LLC -385220,NF,74,Regency Albany,805 19th St. SE,"Albany, OR 97322",,"Regency Albany, LLC","Regency Pacific Management, LLC" -385221,NF,102,Marquis Oregon City Post Acute Rehab,1680 Molalla Avenue,"Oregon City, OR 97045",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -385222,NF,92,Meadow Park Health & Specialty Care Center,75 Shore Drive,"St Helens, OR 97051",,"FMG Shore Drive Oregon, LLC","FMG Shore Drive Oregon, LLC" -385224,NF,100,Windsor Health and Rehabilitation Center,820 Cottage St NE,"Salem, OR 97301",,Evergreen Oregon Healthcare Salem L.L.C.,"EmpRes Healthcare Management, LLC" -385225,NF,96,Prestige Post-Acute and Rehabilitation Center - McMinnville,421 S Evans St,"McMinnville, OR 97128",,Care Center (McMinnville) Inc.,"Prestige Care, Inc." -385228,NF,105,Portland Health and Rehabilitation Center,12441 SE Stark St,"Portland, OR 97233",,"Evergreen Oregon Healthcare Portland, L.L.C.","EmpRes Healthcare Management, LLC" -385229,NF,53,Avamere Rehabilitation of Junction City,530 Birch St,"Junction City, OR 97448",,"Junction City Rehabilitation, LLC.","Junction City Rehabilitation, LLC." -385230,NF,50,Regency Redmond Rehabilitation and Nursing Center,3025 SW Reservoir,"Redmond, OR 97756",,"BD Redmond IV, LLC","Regency Pacific Management, LLC" -385232,NF,44,Laurel Hill Nursing Center,859 NE Sixth St,"Grants Pass, OR 97526",,"BD Grants Pass II, LLC","Regency Pacific Management, LLC" -385233,NF,69,Avamere Court at Keizer,5210 River Rd N,"Keizer, OR 97303",,"Keizer Campus Operations, LLC","Keizer Campus Operations, LLC" -385234,NF,80,Salem Transitional Care,3445 Boone Road SE,"Salem, OR 97317",,"South Salem Rehabilitation, LLC.","South Salem Rehabilitation, LLC." -385236,NF,51,Town Center Village Rehab,8607 SE Causey Ave,"Portland, OR 97086",,"TVC Employees, LLC","Generations, LLC" -385237,NF,63,Fernhill Estates,5737 NE 37th,"Portland, OR 97211",,"Fernhill Estates, LLC","Dakavia Management, Corp." -385239,NF,92,Avamere Rehabilitation of Coos Bay,2625 Koos Bay Blvd,"Coos Bay, OR 97420",,"Coos Bay Rehabilitation, LLC.","Coos Bay Rehabilitation, LLC." -385240,NF,214,Marian Estates,390 Church St,"Sublimity, OR 97385",,"Ernmaur, Inc.",Marian Estates Support Services -385241,NF,49,Sherwood Park Nursing & Rehab Center,4062 Arleta Ave NE,"Keizer, OR 97303",,"Sherwood Park Nursing Home, Inc.","Sherwood Park Nursing Home, Inc." -385242,NF,41,Avamere Twin Oaks of Sweet Home,950 Nandina Street,"Sweet Home, OR 97386",,"Twin Oaks Rehab, LLC.","Twin Oaks Rehab, LLC." -385244,NF,50,Nehalem Valley Care Center,"PO Box 6, 280 Rowe St","Wheeler, OR 97147",,"Wheeler Care Center, LLC","Aidan Health Services, Inc." -385245,NF,53,Oregon City Health Care Center,148 Hood St,"Oregon City, OR 97045",,Care Center (Oregon City) Inc.,"Prestige Care, Inc." -385250,NF,68,Rogue Valley Manor Health Center,1200 Mira Mar Ave,"Medford, OR 97504",,Rogue Valley Manor,"Pacific Retirement Services, Inc." -385251,NF,87,Avamere Rehabilitation of Hillsboro,650 SE Oak St,"Hillsboro, OR 97123",,"Peckham-Miller, Inc. dba","Peckham-Miller, Inc." -385253,NF,49,Bend Transitional Care,900 NE 27th Street,"Bend, OR 97701",,"Ohana Harmony House, LLC","Ohana Harmony House, LLC" -385254,NF,35,Myrtle Point Care Center, 637 Ash St,"Myrtle Point, OR 97458",,"Care Centers Management, Inc.","Dakavia Management, Corp." -385257,NF,151,Oregon Veterans' Home,700 Veterans Drive,"The Dalles, OR 97058",,Oregon Dept Of Veterans Affairs,Veterans Care Centers of Oregon -385258,NF,55,Park Forest Care Center,8643 NE Beech St,"Portland, OR 97220",,Care Center ( Park Forest) Inc.,"Prestige Care, Inc." -385259,NF,51,Holladay Park Plaza,1300 NE 16th Ave,"Portland, OR 97232",,"Holladay Park Plaza, Inc.","Pacific Retirement Services, Inc." -385260,NF,50,Marquis Hope Village,1577 S Ivy,"Canby, OR 97013",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385261,NF,44,Regency Prineville Rehabilitation and Nursing Center,950 NE Elm Street,"Prineville, OR 97754",,"BD Prineville II, LLC","Regency Pacific Management, LLC" -385262,NF,52,Marquis Silver Garden,115 S James St,"Silverton, OR 97381",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -385263,NF,105,Regency Hermiston Nursing & Rehabilitation Center,970 W Juniper Ave,"Hermiston, OR 97838",,"Regency Hermiston Nursing & Rehabilitation Center, LLC","Regency Pacific Management, LLC" -385264,NF,53,"Trinity Mission Health & Rehab of Portland, LLC",10435 SE Cora,"Portland, OR 97266",,"Trinity Mission Health & Rehab of Portland, LLC","Trinity Mission Health & Rehab of Portland, LLC" -385265,NF,5,Mary's Woods at Marylhurst,17360 Holy Names Drive,"Lake Oswego, OR 97034",,"Mary's Woods at Marylhurst, Inc.","Mary's Woods at Marylhurst, Inc." -385266,NF,50,Marquis Wilsonville Post Acute Rehab,30900 SW Parkway Avenue,"Wilsonville, OR 97070",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -385268,NF,59,Gateway Care & Retirement Center,39 NE 102nd,"Portland, OR 97220",,"Sapphire at Gateway, LCC","Sapphire at Gateway, LLC" -385270,NF,96,Prestige Post-Acute and Rehabilitation Center - Milwaukie,12045 SE Stanley Ave.,"Milwaukie, OR 97222",,"Care Center (Milwaukie), Inc.","Prestige Care, Inc." -385271,NF,45,"Pearl at Kruse Way, The",4550 Carman Drive,"Lake Oswego, OR 97035",,"Avamere Lake Oswego Operations Investors, LLC","Avamere Lake Oswego Operations Investors, LLC" -385272,NF,112,Pacific Health and Rehabilitation,14145 SW 105th Ave.,"Tigard, OR 97224",,"Pacific Gardens Estates, LLC","Dakavia Management, Corp." -385273,NF,33,Pioneer Nursing Home,1060 D Street W,"Vale, OR 97918",,Pioneer Nursing Home Health District,Pioneer Nursing Home Health District -385275,NF,51,Sheridan Care Center,411 SE Sheridan Road,"Sheridan, OR 97378",,"Sheridan Care Center, LLC ","Dakavia Management, Corp." -38A001,NF,58,Providence Child Center,830 NE 47th Ave,"Portland, OR 97213",,Providence Health & Services - Oregon,Providence Health & Services - Oregon -38A026,NF,39,Marquis Autumn Hills Memory Care,6630 SW Beav-Hillsdale Hwy,"Portland, OR 97225",,"Marquis Companies II, Inc.","Marquis Companies II, Inc." -3.80E+19,NF,71,Rose Linn Care Center,2330 Debok,"West Linn, OR 97068",,"West Linn Care Center Operating Company, LLC","Benicia Senior Living, LLC" -3.80E+25,NF,40,Columbia Care Center,33910 E Columbia Ave PO Box 1068,"Scappoose, OR 97056",,EEA Company,EEA Company -3.80E+33,NF,46,Regency Care of Central Oregon,119 SE Wilson Ave,"Bend, OR 97702",,"BD Bend III, LLC","Regency Pacific Management, LLC" -3.80E+41,NF,40,Blue Mountain Care Center,112 E Fifth St-PO Box 305,"Prairie City, OR 97869",,Blue Mountain Hospital District,Blue Mountain Hospital District -3.80E+76,NF,76,Tierra Rose Care Center,4254 Weathers St NE,"Salem, OR 97301",,"CML, Inc.","CML, Inc." -3.80E+127,NF,114,Healthcare at Foster Creek,6003 SE 136th,"Portland, OR 97236",,"St. Jude Operating Company, LLC","Benicia Senior Living, LLC" -3.80E+158,NF,30,Rose City Nursing Home,34 NE 20th,"Portland, OR 97232",,"Geistlinger Enterprises, Inc.","Geistlinger Enterprises, Inc." -3.80E+174,NF,40,Cornerstone Care Option,12640 SE Bush,"Portland, OR 97236",,"Cornerstone Care Option, Inc","Cornerstone Care Option, Inc." -3.80E+175,NF,60,Village Manor,2060 NE 238th Drive,"Wood Village, OR 97060",,"V.M.C., Inc.","V.M.C., Inc." -3.80E+189,NF,80,Gracelen Terrace Long Term Care Facility,10948 SE Boise St,"Portland, OR 97266",,"H & L Care Centers, Inc.","H & L Care Centers, Inc." -3.80E+197,NF,41,Lawrence Convalescent Center,812 SE 48th Ave,"Portland, OR 97215",,Charles Lawrence,Charles Lawrence -38L300,NF,54,Marquis Tualatin Post Acute Rehab,19945 SW Boones Ferry,"Tualatin, Oregon, OR 97062",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -38L400,NF,44,Mirabella Portland,3550 SW Bond Ave.,"Portland, OR 97239",,Mirabella at South Waterfront,"Pacific Retirement Services, Inc." -38L501,NF,20,Village at Hillside,440 NW Hillside Parkway,"McMinnville, OR 97128",,"EmeriCare, Inc","EmeriCare, Inc." -38L503,NF,154,Lebanon Veterans Home,600 North 5th Street,"Lebanon, OR 97355",,Oregon Dept Of Veterans Affairs,Veterans Care Centers of Oregon -38L544,NF,45,Rose Villa Senior Living,13505 SE River Rd,"Portland, OR 97222",,"Rose Villa, Inc.","Rose Villa, Inc." -38L756,NF,32,Cascade Manor,65 West 30th,"Eugene, OR 97405",,"Cascade Manor, Inc.","Pacific Retirement Services, Inc." -50A028,RCF,70,Farmington Square - Beaverton,14420 SW Farmington Rd,"Beaverton, OR 97005",,"RSL Beaverton, LLC","Radiant Senior Living, Inc." -50A235,RCF,20,Avamere at Waterford,760 Spring Street,"Medford, OR 97504",,"Waterford Operations, LLC","Waterford Operations, LLC" -50A236,RCF,60,Brookdale Troutdale,1201 SW Cherry Park Rd.,"Troutdale, OR 97060",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50A239,RCF,48,"Regent Court, a Blue Harbor Senior Living Community",400 NW Elks Drive,"Corvallis, OR 97330",,Regent Court Management LLC,Regent Court Management LLC -50A244,RCF,22,Marquis Autumn Hills Residential Memory Care,6630 SW Beaverton-Hillsdale Hwy.,"Portland, OR 97225",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -50A253,RCF,58,Bridgecreek Memory Care Community,1401 12th St,"Lebanon, OR 97355",,"Bridgecreek Investors, LLC","Ageia Health Services, LLC" -50A262,RCF,24,Providence Brookside Memory Care,1550 Brookside Dr.,"Hood River, OR 97031",,Providence Health & Services - Oregon,Providence Health System - Oregon -50A263,RCF,59,Brookdale Bend,1099 NE Watt Way,"Bend, OR 97701",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50M006,RCF,10,"Autumn Garden Home RCF, Inc.",6215 SE Hazel Ave.,"Portland, OR 97206",,"Autumn Garden Home RCF, LLC","Autumn Garden Home RCF, LLC" -50M012,RCF,32,Cascade Park Retirement Center,950 N Cascade Dr,"Woodburn, OR 97071",,"Woodburn Investment Associates, Ltd.","Century Park Associates, LLC" -50M019,RCF,59,Emerald Gardens,1890 N Newberg Hwy,"Woodburn, OR 97071",,"RSL Woodburn, LLC","Radiant Senior Living, Inc." -50M021,RCF,16,Comfort Care,1735 Kane St,"Klamath Falls, OR 97603",,Mary Nork,Mary Nork -50M025,RCF,15,Elderly Care Home,12435 SW 121st,"Tigard, OR 97223",,"Elderly Care Home, Inc.","Elderly Care Home, Inc." -50M026,RCF,34,Ellendale Residential Care Center,511 E Ellendale Ave,"Dallas, OR 97338",,"Dallas Care Center, Inc.","Dallas Care Center, Inc." -50M037,RCF,85,Firwood Gardens RCF,819 NE 122nd Ave,"Portland, OR 97230",,"Sapphire at Firwood, LLC","Sapphire at Firwood, LLC" -50M044,RCF,50,Golden Acres Retirement Center,12711 SE Holgate Blvd,"Portland, OR 97236",,Sandra Tidwell,Sandra Tidwell -50M048,RCF,13,Donham Place,5833 N Lombard St,"Portland, OR 97203",,"Donham Place, LLC","Donham Place, LLC" -50M049,RCF,62,Harmony Guest Home,351 SE Fifth St,"Hillsboro, OR 97123",,"Harmony Guest Home, Inc.","Harmony Guest Home, Inc." -50M054,RCF,120,Brookdale River Valley - Tualatin,19200 SW 65th Ave,"Tualatin, OR 97062",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -50M055,RCF,88,Brookdale Mt. Hood,25200 SE Stark St,"Gresham, OR 97030",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50M056,RCF,95,Brookdale Medford,3033 Barnett Rd,"Medford, OR 97504",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50M065,RCF,50,Jefferson Lodge Memory Care Community,664 SE Jefferson St,"Dallas, OR 97338",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -50M081,RCF,23,Milwaukie Care Center,14107 SE Redwood Ave,"Milwaukie, OR 97222",,"Milwaukie Care Center, Inc.","Milwaukie Care Center, Inc." -50M086,RCF,46,Mt. Scott Residential Care Home,8014 SE Lambert St,"Portland, OR 97206",,"Sistere, Inc.","Sistere, Inc." -50M088,RCF,20,Myrtle Point Care Center RCF,637 Ash St,"Myrtle Point, OR 97458",,"Care Centers Management, Inc.","Dakavia Management, Corp." -50M092,RCF,32,O'Hara's Manor,1250 SE Roberts,"Gresham, OR 97080",,"O'Hara's Manor, Inc.","O'Hara's Manor, Inc." -50M094,RCF,50,Oregon City Residential Care,515 10th St,"Oregon City, OR 97045",,"Valley View Care Centers, Inc.","Valley View Care Centers, Inc." -50M096,RCF,14,Our House Of Portland,2727 SE Alder,"Portland, OR 97214",,"Our House Of Portland, Inc","Our House of Portland, Inc." -50M098,RCF,,Aaren Brooke Place,995 N Oregon St,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50M098,RCF,14,Aaren Brooke Place,995 N Oregon St,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50M109,RCF,30,Tabor Crest Residential Care,7430 SE Division St,"Portland, OR 97206",,"Tabor Crest Residential Care, LLC","Tabor Crest Residential Care, LLC" -50M110,RCF,80,"Taft Home, The",1337 SW Washington St,"Portland, OR 97205",,"Concepts in Community Living, Inc.","Concepts in Community Living, Inc." -50M124,RCF,30,Harmony Estates Residential Care Center,87326 McTimmons Lane,"Bandon, OR 97411",,"Harmony Estates, Inc.","Harmony Estates, Inc." -50M132,RCF,60,River Grove Memory Care,140 Green Lane,"Eugene, OR 97404",,River Grove Operating Company,"Benecia Senior Living, LLC" -50M133,RCF,74,Oak Lane Retirement,727 SW Rogue River Ave,"Grants Pass, OR 97526",,"TSL Oak Lane, LLC","Tierra Senior Living, LLC" -50M138,RCF,36,Baycrest Assisted Care,3959 Sheridan Ave,"North Bend, OR 97459",,"Bay Area Properties, LLC","Radiant Senior Living, Inc." -50M142,RCF,82,Brookdale Ontario,1372 SW 8th Ave,"Ontario, OR 97914",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -50M144,RCF,50,Elizabethan Manor,44882 Mission Road,"Pendleton, OR 97801",,"Prestige Residential Community, L.L.C","Prestige Senior Living, L.L.C" -50M154,RCF,15,Forest Meadows RCF,625 Barbara Dr,"Grants Pass, OR 97526",,"Forest Meadows RCF, Inc.","Forest Meadows RCF, Inc." -50M157,RCF,29,Terwilliger Plaza - Metcalf Unit,2545 SW Terwilliger Blvd,"Portland, OR 97201",,"Terwilliger Plaza, Inc.","Terwilliger Plaza, Inc." -50M172,RCF,28,Chateau Gardens Memory Care Community,2669 S Cloverleaf Loop,"Springfield, OR 97477",,"Cloverleaf Assisted Living, LLC",Ridgeline Management Co. -50M174,RCF,85,"Woods at Willowcreek, The",4398 Glencoe St NE,"Salem, OR 97301",,"Lancaster Woods Operator, LLC","The Springs Living, LLC" -50M201,RCF,19,Haven House Retirement Center,714 Main Street PO Bos 386,"Fossil, OR 97830",,"Fossil Elderly Housing Committee, Inc.","Fossil Elderly Housing Committee, Inc." -50M204,RCF,9,Ashley Manor - Lund Lane,1040 Lund Lane,"Baker City, OR 97814",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50M208,RCF,37,Chetco Inn Residential Care Facility,417 Fern St,"Brookings, OR 97415",,Chetco Inn RCF Incorporated,Chetco Inn RCF Incorporated -50M209,RCF,36,Forest Glen Senior Residence,200 SW Frontage Rd.,"Canyonville, OR 97417",,Aspen Foundation,Aspen Foundation -50M211,RCF,28,Hill House,1325 SW Gibbs Street,"Portland, OR 97239",,"Peaks and Valleys, LLC","Peaks and Valleys, LLC" -50M218,RCF,42,Meadows Courtyard,13637 Garden Meadow Drive,"Oregon City, OR 97045",,"Meadows Courtyard, Inc.","Meadows Courtyard, Inc." -50M220,RCF,15,Ashley Manor - Shasta,475 S Shasta Pl. Longview Div.,"Burns, OR 97720",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50M225,RCF,16,Blue Haven RCF - Independence,202 South 9th Street,"Independence, OR 97351",,"Blue Haven Residential Care Facilities, Inc.","Blue Haven Residential Care Facilities, Inc." -50M227,RCF,16,Blue Haven RCF - Dallas,280 SE Uglow St,"Dallas, OR 97338",,"Blue Haven Residential Care Facilities, Inc.","Blue Haven Residential Care Facilities, Inc." -50M228,RCF,32,Brookdale Wilsonville,8170 Vlahos Drive,"Wilsonville, OR 97070",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -50M247,RCF,11,Pleasant Valley RCF,18857 SE Giese Rd.,"Gresham, OR 97080",,"BME Enterprises, Inc.","BME Enterprises, Inc." -50M264,RCF,16,Sherwood Pines Residential Care,87986 Sherwood,"Veneta, OR 97487",,"Sherwood Pines Residential Care, Inc.","Sherwood Pines Residential Care, Inc." -50M265,RCF,15,Ashley Manor - Rimrock,1600 SW Rimrock Way,"Redmond, OR 97756",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50M267,RCF,15,Ashley Manor - Pacific Heights,1995 8th St.,"Hood River, OR 97031",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50M268,RCF,32,Four Seasons RCF - Fairgrounds,2850 Evergreen Ave NE,"Salem, OR 97303",,Four Seasons RCF Fairgrounds,Four Seasons RCF Fairgrounds -50M300,RCF,44,Quail Park Memory Care Residences of Klamath Falls,320 Jade Terrace,"Klamath Falls, OR 97601",,"Quail Park of Klamath Falls Phase II, LLC",Living Care Lifestyles -50M422,RCF,16,Juniper House Memory Care,301 SW 28th Drive,"Pendleton, OR 97801",,Assisted Living Facilities Inc.,"Concepts in Community Living, Inc." -50M423,RCF,45,Marjorie House Memory Care Community,2855 NE Cumulus Avenue,"McMinnville, OR 97128",,"Marjorie House McMinnville, LLC","Marjorie House McMinnville, LLC" -50M424,RCF,30,Kinsington at Redwood Park,1390 Dowell Road,"Grants Pass, OR 97527",,"Heirloom Living Centers, LLC","Cameo Care Management, LLC" -50M425,RCF,28,Maple Valley Dementia Care,219 NE Fircrest Drive,"McMinnville, OR 97128",,"Maple Valley Dementia Care, Inc.","Maple Valley Dementia Care, Inc." -50M426,RCF,35,Countryside Living of Redmond,1350 NW Canal Blvd,"Redmond, OR 97756",,"Countryside Living of Redmond, LLC","Countryside Living of Redmond, LLC" -50M427,RCF,23,"Village at Keizer Ridge Memory Care, The",1165 McGee Court,"Keizer, OR 97303",,"VKR, LLC","Keizer Care Properties, LLC" -50R009,RCF,74,Pacifica Senior Living Calaroga Terrace,1400 NE Second Ave,"Portland, OR 97232",,"Pacifica Senior Living, LLC","Pacifica Senior Living, LLC" -50R014,RCF,49,Cherry Blossom Cottage,11177 SE Cherry Blossom Dr,"Portland, OR 97216",,"Sylvia's Legacy, Inc.","Sylvia's Legacy, Inc." -50R023,RCF,51,Conifer House Residential Care & Memory Care,145 NE Conifer Blvd,"Corvallis, OR 97330",,"Conifer House Operating Company, LLC","Benicia Senior Living, LLC" -50R038,RCF,19,Fountain Plaza,1441 Morrow Rd,"Medford, OR 97504",,"Fountain Plaza, L.L.C.","Dharma Healthcare Management, Inc." -50R040,RCF,155,Friendsview Retirement Community,1301 E Fulton St,"Newberg, OR 97132",,"Friendsview Manor, Inc.","Friendsview Manor, Inc." -50R046,RCF,54,Fox Hollow Residential Care Community,5320 Fox Hollow Rd,"Eugene, OR 97405",,"Regency At Fox Hollow, Inc.",Prestige Care Inc. -50R062,RCF,7,Hubbard Residential Care Facility,647 Junction Rd,"Glendale, OR 97442",,Norma Ann Hubbard,Norma Ann Hubbard -50R068,RCF,63,Avamere Court at Keizer RCF,5210 River Road N,"Keizer, OR 97307",,"Keizer Campus Operations, LLC","Keizer Campus Operations, LLC" -50R078,RCF,35,Brookdale McMinnville Town Center,775 East 27th,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50R085,RCF,29,Mt. Angel Towers,One Towers Lane Box 2120,"Mt. Angel, OR 97362",,"Mt. Angel Towers, Oregon, Ltd.","Mt. Angel Towers, Oregon, Ltd." -50R091,RCF,115,Odd Fellows Home Of Oregon,3102 SE Holgate Blvd,"Portland, OR 97202",,Odd Fellows Home of Oregon,Odd Fellows Home of Oregon -50R108,RCF,39,Sweetbriar Villa,6135 E St.,"Springfield, OR 97478",,"RSL Springfield, LLC","Radiant Senior Living, Inc." -50R115,RCF,48,Turner Retirement Homes,5405 Boise Street,"Turner, OR 97392",,"Turner Retirement Homes, Inc.","Turner Retirement Homes, Inc." -50R121,RCF,150,West Hills Village Senior Residence,5711 SW Multnomah Blvd,"Portland, OR 97219",,West Hills Village Limited Partnership,"West Hills Village, LP" -50R125,RCF,60,Willson House Residential Care Facility,1625 Center St NE,"Salem, OR 97301",,United Methodist Retirement Center Inc.,"Concepts in Community Living, Inc." -50R126,RCF,40,Regency Woodland,4710 Sunnyside Rd SE,"Salem, OR 97302",,"BD Salem I, LLC","Regency Pacific Management, LLC" -50R128,RCF,70,Cascades of Bend Retirement Community,1801 NE Lotus Dr,"Bend, OR 97701",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -50A034,RCF,122,Farmington Square - Salem,910 Boone Rd SE,"Salem, OR 97306",,"RSL Salem, LLC","Radiant Senior Living, Inc." -50A070,RCF,49,Regency Park Alzheimer's Care,8300 SW Barnes Rd,"Portland, OR 97225",,Regency Park Apartments Ltd Part.,"Regency Park Management, LLC" -50A074,RCF,42,Holly Residential Care Center,1075 Irvington Drive,"Eugene, OR 97404",,The Maren Corporation,The Maren Corporation -50A083,RCF,81,Farmington Square - Medford,1530 Poplar Dr,"Medford, OR 97504",,"RSL Medford, LLC","Radiant Senior Living, Inc." -50A143,RCF,64,Farmington Square - Tualatin,17950 SW 115th Ave,"Tualatin, OR 97062",,"RSL Tualatin, LLC","Radiant Senior Living, Inc." -50A149,RCF,66,Farmington Square - Eugene,2730 Bailey Lane,"Eugene, OR 97401",,"RSL Eugene, LLC","Radiant Senior Living, Inc." -50A165,RCF,32,"Regent at Sheldon Park, a Blue Harbor Senior Living Community",2440 Willakenzie Road,"Eugene, OR 97401",,Sheldon Park Management LLC,Sheldon Park Management LLC -50A214,RCF,48,Monterey Court Memory Care,8915 SE Monterey,"Happy Valley, OR 97086",,"Monterey Court Ventures, LLC","Frontier Management, LLC" -50A219,RCF,20,Expressions at Summerplace,15727 NE Russell Street,"Portland, OR 97230",,"Summerplace Assisted Living, LLC","Prestige Senior Living, L.L.C" -50A226,RCF,30,Settler's Park Memory Care Community,2895 17th Street,"Baker City, OR 97814",,LSREF Golden Ops 26 (OR) LLC,"SLH Rainier Manager, LLC" -50A232,RCF,60,Brookdale Beaverton,16655 NW Walker Rd,"Beaverton, OR 97006",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50R139,RCF,40,Clackamas View Senior Living - Milwaukie,14550 SE Vista Ln,"Milwaukie, OR 97267",,"Chancellor Health Care of California X, Inc.","Chancellor Health Care, Inc," -50R145,RCF,17,Horton Plaza,1122 Spring St,"Medford, OR 97504",,Horton Plaza A Joint Venture,"Dharma Healthcare Management, Inc." -50R171,RCF,16,Oaktree Residential Living,5030 West Port St PO Box 22636,"Eugene, OR 97402",,Elman's House Corp.,Elman's House Corp. -50R200,RCF,22,Willamette Lutheran Retirement Community,7693 Wheatland Rd,"Salem, OR 97308",,"Willamette Lutheran Homes, Inc.","Willamette Lutheran Homes, Inc." -50R202,RCF,20,Riverview Terrace,1970 West Harvard Avenue,"Roseburg, OR 97470",,Crown One Development LLC,"Crown Two Development, LLC" -50R216,RCF,102,Capital Manor Retirement Community,1955 Salem Dallas Hwy NW,"Salem, OR 97304",,"Capital Manor, Inc.","Life Care Services, LLC" -50R229,RCF,96,Willamette View Terrace,13169 SE River Road,"Portland, OR 97222",,"Willamette View, Inc. dba","Willamette View, Inc." -50R230,RCF,44,Holladay Park Plaza,1300 NE 16th,"Portland, OR 97232",,"Holladay Park Plaza, Inc.","Pacific Retirement Services, Inc." -50R234,RCF,38,"Springs at Anna Maria, The",822 Golf View Drive,"Medford, OR 97504",,"HSRE-Springs III at Medford AM sub-TRS, LLC","The Springs Living, LLC" -50R251,RCF,16,Ivy Court Senior Living,18265 SE River Road,"Milwaukie, OR 97222",,"Ivy Court Senior Living, Inc.","Ivy Court Senior Living, Inc." -50R256,RCF,15,Elite Care Oatfield Estates-Hood House,4499 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" -50R270,RCF,70,Rose Linn Vintage Place,2330 Debok Rd,"West Linn, OR 97068",,West Linn Care Center Operating Co LLC,"Benecia Senior Living, LLC" -50R271,RCF,21,Willamette View Memory Care Community,13145 SE River Rd,"Portland, OR 97222",,"Willamette View, Inc.","Willamette View, Inc." -50R273,RCF,27,Suttle Care & Retirement,1601 SW 24th St.,"Pendleton, OR 97801",,"Suttle Care & Retirement, Inc.","Suttle Care & Retirement, Inc." -50R274,RCF,11,Ashley Manor - Arrowhead,3853 Arrowhead Dr.,"Medford, OR 97504",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50R275,RCF,28,Avamere at St. Helens,2400 Gable Rd.,"St. Helens, OR 97051",,"Avamere - St. Helens Operations, LLC","Avamere-St. Helens Operations, LLC " -50R276,RCF,27,Edgewood Arbor Memory Care,7733 SW Scholls Ferry Rd.,"Beaverton, OR 97008",,"Beaverton Assisted Living, LLC","Hawthorn Retirement Group, LLC" -50R277,RCF,20,Courtyard at Hillside Memory Care,300 NW Hillside Park Way,"McMinnville, OR 97128",,Emeritus Corporation,Emeritus Corporation -50R278,RCF,25,Manor Special Care Center,1200 Mira Mar Ave.,"Medford, OR 97504",,"Rogue Valley Manor, Inc.","Pacific Retirement Services, Inc." -50R279,RCF,64,Brookdale Eugene Alpine Court Memory Care,3720 N. Clarey St,"Eugene, OR 97402",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -50R280,RCF,48,Elderberry Square Community,3321 Oak St,"Florence, OR 97439",,"Elderberry Square Community, LLC","Senior Housing Managers, LLC" -50R281,RCF,15,Ashley Manor - Conners,2853 NE Conners Ave.,"Bend, OR 97701",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50R282,RCF,15,Elite Care Oatfield Estates-Adam's House,4483 SE Oatfield Hill Rd,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" -50R283,RCF,35,Countryside Living of Canby,390 NW 2nd,"Canby, OR 97013",,"Countryside Living of Canby, LLC","Countryside Living of Canby, LLC" -50R285,RCF,18,West Wind Court,465 4th St. SW,"Bandon, OR 97411",,West Wind Court Corporation,West Wind Court Corporation -50R287,RCF,21,Raleigh Hills Enhanced Care Community,4815 SW Dogwood Ln,"Portland, OR 97225",,"Raleigh Hills Management, LLC","Raleigh Hills Management, LLC" -50R288,RCF,15,Ashley Manor - Athens,1514 Athens Ave.,"Pendleton, OR 97801",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50R289,RCF,15,Elite Care Oatfield Estates-Helen's House,4469 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" -50R290,RCF,48,Rosewood Specialty Care,2550 SE Century Blvd.,"Hillsboro, OR 97123",,"Brookwood Court Assisted Living, LLC","Hillsboro Care Properties, LLC" -50R292,RCF,43,Quail Park of Klamath Falls,1000 Town Center Dr.,"Klamath Falls OR, OR 97601",,"Quail Park of Klamath Falls, LLC",Living Care Lifestyles -50R293,RCF,186,Miramont Pointe,11520 SE Sunnyside Rd,"Clackamas, OR 97015",,"MP, LLC","MP, LLC" -50R294,RCF,142,Hearthstone at Murrayhill,10880 SW Davies Rd.,"Beaverton, OR 97008",,"Hearthstone at Murrayhill, LLC","Hearthstone Management Services, LLC" -50R295,RCF,15,Ashley Manor - Anique,525 Anique Ln,"Grants Pass, OR 97526",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50R296,RCF,40,Avamere at Seaside Residential Care Facility,2500 S. Roosevelt Dr.,"Seaside, OR 97138",,"Necanicum Operations, LLC","Necanicum Operations, LLC" -50R297,RCF,18,Prestige Senior Living Orchard Heights Memory Care,695 Orchard Heights Rd. NW,"Salem, OR 97304",,CHP Salem-Orchard Heights OR Tenant Corp.,"Prestige Senior Living, LLC" -50R298,RCF,16,Sweet Bye N Bye,2480 Coral Ave NE,"Salem, OR 97305",,"Sweet Bye N Bye AFC & RCF Facilities, Inc.","Sweet Bye N Bye AFC & RCF Facilities, Inc." -50R300,RCF,15,Hawthorne House of Salem,3042 Hyacinth St. NE,"Salem, OR 97303",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R301,RCF,55,Emerson House,3577 SE Division,"Portland, OR 97202",,"Emerson House, LLC","Kinsel Ameri Properties, Inc." -50R302,RCF,48,Timberwood Court Specialty Care Community,2875 SE 14th Ave,"Albany, OR 97321",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" -50R303,RCF,16,SpringRidge Court Memory Care,32100 SW French Prairie Rd,"Wilsonville, OR 97070",,Spring Ridge Subtenant LLC,"SRG Management, LLC" -50R304,RCF,90,Gateway Gardens,178 Commons Dr.,"Eugene, OR 97401",,"Gateway Gardens Assisted Living, Inc.","Gateway Gardens Assisted Living, Inc." -50R305,RCF,52,Evergreen Court of Molalla,250 Kennel St.,"Molalla, OR 97038",,"Molalla Senior Living, LLC","Avant Senior Housing Managers & Consultants, LLC" -50R306,RCF,15,Ashley Manor - Homedale,44 North Homedale Rd.,"Klamath Falls, OR 97601",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -50R307,RCF,13,"Touch of Grace, A","PO Box 165, 2156 Brookhurst St.","Medford, OR 97504",,"A Touch of Grace, LLC","A Touch of Grace, LLC" -50R308,RCF,15,Elite Care Oatfield Estates-Rainier House,4457 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" -50R309,RCF,16,Silvia & John's Residential Care,19909 SE Stark St.,"Portland, OR 97233",,"Silvia & John's Residential Care, Inc.","Silvia & John's Residential Care, Inc." -50R310,RCF,50,Rosewood Court Residential Care,4254 Weathers Street NE,"Salem, OR 97301",,"Capri Senior Living, LLC","Capri Senior Living , LLC" -50R311,RCF,43,"Gardens, The",2690 NE Yacht,"Lincoln City, OR 97367",,"Lakeview Operations, LLC","Westmont Living, Inc." -50R313,RCF,18,Prairie House Memory Care Community,51485 Morson St.,"La Pine, OR 97739",,"Assisted Living Alternatives, Inc.",Ridgeline Management Co. -50R314,RCF,15,Magnolia Village Memory Care Community,1355 Daugherty,"Cottage Grove, OR 97424",,"Magnolia Village, LLC","Magnolia Gardens, LLC" -50R315,RCF,16,All Comfort Residential Care,9347 SW 35th St.,"Portland, OR 97219",,"Peaks and Valleys, LLC","Peaks and Valleys, LLC" -50R316,RCF,64,Hope N Care,12045 SE Pardee St.,"Portland, OR 97266",,"Asa Care, Inc.","Asa Care, Inc." -50R318,RCF,15,Elite Care Oatfield Estates-Jefferson House,4422 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" -50R319,RCF,15,"Golden Age Living, LLC",3484 SE Hill Rd.,"Milwaukie, OR 97267",,Golden Age Living LLC,Golden Age Living LLC -50R320,RCF,26,Avamere at Bethany,16360 NW Avamere Court,"Portland, OR 97229",,"Avamere Bethany Operations, LLC","Avamere Bethany Operations, LLC" -50R321,RCF,42,Providence ElderPlace in Cully,5119 NE 57th Ave.,"Portland, OR 97218",,Providence Health & Services - Oregon,Providence Health & Services - Oregon -50R322,RCF,23,Mountain View Residential Care Facility,1220 SE 282nd Ave.,"Gresham, OR 97080",,"BME Enterprises, Inc.",Fred T. & Elizabeth C. Asa -50R323,RCF,18,Prestige Senior Living Arbor Place Memory Care,3150 Juanipero Way,"Medford, OR 97504",,CHP Medford -Arbor Place OR Tenant Corp.,"Prestige Senior Living, L.L.C" -50R326,RCF,16,West Wind Enhanced Care,3130 Juanipero St.,"Medford, OR 97504",,"Ashland View Manor, Inc.","Ashland View Manor, Inc." -50R327,RCF,33,"Atrium at Flagstone, The",3325 Columbia View Dr.,"The Dalles, OR 97058",,"Flagstone Operations, LLC.","Milestone Retirement Communities, LLC" -50R328,RCF,15,Arbor House of Grants Pass,820 Gold Court,"Grants Pass, OR 97527",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R330,RCF,15,Elite Care Oatfield Estates-Ashland House,4398 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" -50R331,RCF,20,Dallas Retirement Village Memory Care Center,340 NW Brentwood Avenue,"Dallas, OR 97338",,"Dallas Health Care Center, LLC",Life Care Services -50R332,RCF,15,Heritage House of Woodburn,943 N. Cascade Dr.,"Woodburn, OR 97071",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R333,RCF,56,Laurel Pines Retirement Lodge,3100 Avenue A,"White City, OR 97503",,"Laurel Pines, Inc.","Dakavia Management, Corp." -50R334,RCF,16,East Cascade Memory Care Community,175 NE 16th Street,"Madras, OR 97741",,"East Cascade Retirement Community, LLC","Senior Housing Managers, LLC" -50R336,RCF,31,Oswego Grove,4550 SW Carman Drive,"Lake Oswego, OR 97035",,"Avamere Lake Oswego Operations Investors, LLC","Avamere Lake Oswego Operations Investors, LLC" -50R339,RCF,15,Angeline Senior Living,501 3rd St.,"La Grande, OR 97850",,"Angeline Senior Living, LLC","Angeline Senior Living, LLC" -50R340,RCF,30,Fanno Creek by Elite Care,12353 SW Grant St,"Tigard, OR 97223",,"Elite Care Grant, LLC","Elite Care Management Group, LLC" -50R343,RCF,15,Autumn House of Grants Pass,PO Bx 1419 2268 Williams Hwy,"Grants Pass, OR 97528",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R344,RCF,32,Brookdale Redmond Clare Bridge,1942 SW Canyon Drive,"Redmond, OR 97756",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -50R345,RCF,36,Middlefield Oaks Memory Care Community,1500 Village Drive,"Cottage Grove, OR 97424",,"Middlefield Oaks Assisted Living, LLC",Frontline Management -50R346,RCF,16,Cornerstone Residential Option,12640 SE Bush,"Portland, OR 97236",,"Cornerstone Care Option, Inc","Cornerstone Care Option, Inc." -50R347,RCF,14,Bayberry Commons Memory Care,2211 Laura Street,"Springfield, OR 97477",,"Bayberry Commons, Inc.",Ridgeline Management Co. -50R348,RCF,22,Rock of Ages Mennonite Home,15600 SW Rock of Ages Rd.,"McMinnville, OR 97128",,"Bible Mennonite Fellowship, Inc.","Bible Mennonite Fellowship, Inc." -50R349,RCF,95,Touchmark at Mt. Bachelor Village,19800 SW Touchmark Way,"Bend, OR 97702",,"Touchmark at Mt. Bachelor Village, LLC","Touchmark Living Centers, Inc." -50R350,RCF,21,Hawthorne Gardens Memory Care Community,2828 SE Taylor Street,"Portland, OR 97214",,"GF Hawthorne Tenant, LLC","Artegan at Hawthorne Gardens, LLC" -50R351,RCF,45,Chantele's Loving Touch Memory Care,1128 W. Central Avenue,"Sutherlin, OR 97479",,"Chantele's Loving Touch Memory Care, Inc.","Chantele's Loving Touch Memory Care, Inc." -50R352,RCF,12,Pheasant Pointe Memory Care Community,835 E. Main Street,"Molalla, OR 97038",,"ARHC PPMOLOR01 TRS, LLC","FM Pheasant Pointe, LLC" -50R353,RCF,24,Cedar Village Memory Care Community,4452 Lancaster Drive NE,"Salem, OR 97301",,"ARHC CVSALOR01 TRS, LLC","FM Cedar Village, LLC" -50R355,RCF,16,Riverside Living,23500 NE Halsey St.,"Wood Village, OR 97060",,"Riverside Living, Inc.","Riverside Living, Inc." -50R356,RCF,15,Harmony House of Salem,3062 Hyacinth St. NE,"Salem, OR 97301",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R357,RCF,28,McLoughlin Memory Care,1145 Molalla Avenue,"Oregon City, OR 97045",,"McLoughlin Place Operations, LLC","Milestone Retirement Communities, LLC" -50R358,RCF,52,Fircrest Memory Care,213 NE Fircrest Drive,"McMinnville, OR 97128",,"Fircrest Community Living, Inc.","Fircrest Community Living, Inc." -50R359,RCF,25,Spruce Point Memory Care,375 9th Street,"Florence, OR 97439",,"Spruce Point, Inc.",Prestige Care Inc. -50R360,RCF,20,Russellville Park West Memory Care,23 SE 103rd,"Portland, OR 97216",,"Russellvillle III, LLC","Leisure Care, LLC" -50R361,RCF,12,Footsteps at Tanasbourne,1950 NW 192nd Avenue,"Hillsboro, OR 97006",,"Springs at Tanasbourne II, LLC","The Springs Living, LLC" -50R363,RCF,30,Manor Terrace Care Suites,1250 Mira Mar Avenue,"Medford, OR 97504",,Rogue Valley Manor,"Pacific Retirement Services, Inc." -50R364,RCF,8,Summit Springs Village MCU,120 S. Church St.,"Condon, OR 97823",,Summit Springs Village Corporation,Summit Springs Village Corporation -50R365,,,Churchill Estates Residential Care,3800 Westleigh,"Eugene, OR 97405",,"Churchill Management, Inc.","Churchill Retirement Services, LLC" -50R366,RCF,44,Tanner Spring Memory Care,23000 Horizon Drive,"West Linn, OR 97068",,Sequoia Heights Capital Partners,"TS Management, LLC" -50R367,RCF,48,Arbor Oaks Terrace Memory Care,317 Werth Blvd.,"Newberg, OR 97132",,"Newberg Memory Associates, LLC","Frontier Management, LLC" -50R368,RCF,35,Brightcreek at Sea View,98059 Gerlach Lane,"Brookings, OR 97415",,"Sea View Assisted Living Community, LLC","Seasons Management, LLC" -50R369,RCF,40,Hillside Care Manor,800 NW 25th Avenue,"Portland, OR 97210",,"Peaks and Valleys, LLC","Peaks and Valleys, LLC" -50R370,RCF,16,Roxy Ann Memory Community,2530 Lone Pine Road,"Medford, OR 97504",,"Roxy Ann Memory Community, LLC","Roxy Ann Memory Community, LLC" -50R371,RCF,15,Applegate House of Grants Pass,1635 Kellenbeck Avenue,"Grants Pass, OR 97528",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R372,RCF,16,Kinsington Place,827 SW Kinsington Court,"Grants Pass, OR 97526",,"Heirloom Living Centers, LLC","Heirloom Living Centers, LLC" -50R373,RCF,20,Silver Creek Memory Care Community,703 Evergreen Rd.,"Woodburn, OR 97071",,"FC Ranger OPS Silver Creek(OR), LLC","Silver Creek Care Properties, LLC" -50R374,RCF,40,Revere Court of Portland,11547 NE Glisan Street,"Portland, OR 97220",,"Chancellor Health Care of California X, Inc.","Chancellor Health Care, Inc," -50R375,RCF,45,RN Villa Care Center,401 NE 139th Avenue,"Portland, OR 97230",,"RN Villa Care Center, LLC","RN Villa Care Center, LLC" -50R376,RCF,22,Hawthorne House,2635 21st Avenue,"Forest Grove, OR 97116",,"Hawthorne House, LLC","Caring Places Management, LLC" -50R377,RCF,32,Footsteps at Clackamas Woods,14314 SE Webster Road,"Milwaukie, OR 97267",,"TSL Clack OPS, LLC","The Springs Living, LLC" -50R378,RCF,60,Adara Oaks Manor,931 NE Linden Avenue,"Gresham, OR 97030",,"Adara Oaks Manor, LLC","Adara Oaks Manor, LLC" -50R379,RCF,84,Fern Gardens Memory Care,2636 Table Rock Rd,"Medford, OR 97504",,"Fern Gardens Memory Care, LLC",Ridgeline Management Co. -50R380,RCF,20,Countryside Living South,406 NW 2nd Avenue,"Canby, OR 97013",,"Countryside Living of Canby, LLC","Countryside Living of Canby, LLC" -50R381,RCF,16,Maryville Memory Care,14645 SW Farmington Road,"Beaverton, OR 97007",,Sisters of St. Mary of Oregon Maryville Corp.,Sisters of St. Mary of Oregon Maryville Corp. -50R382,RCF,48,Washington Gardens Memory Care,9000 SW 91st Avenue,"Tigard, OR 97223",,"Tigard Memory Associates, LLC","Frontier Management, LLC" -50R383,RCF,28,Royalton Place Memory Care,5555 SE King Rd,"Milwaukie, OR 97222",,"BDC/Milwaukie, LLC","Royalton Place Management, LLC" -50R384,RCF,20,Senior Haven Residential Care Facility,12140 SE Foster Road,"Portland, OR 97266",,"Senior Haven RCF, LLC","Senior Haven RCF, LLC" -50R385,RCF,24,Bonaventure of Salem Memory Care,3411 Boone Rd SE,"Salem, OR 97317",,"Bonaventure of Salem, LLC",Bonaventure Senior Living -50R386,RCF,7,Thanksgiving House,184 N 2nd St,"St. Helens, OR 97051",,Cecile Molden,Cecile Molden -50R387,RCF,13,"Griffin House, The",6630 Alderbrook Road,"Tillamook, OR 97141",,The Griffin House LLC,The Griffin House LLC -50R388,RCF,10,Gateway 2 Healthier Living,608 N Cloverleaf Loop,"Springfield, OR 97477",,"Gateway Assisted Living, Inc","Gateway Assisted Living, Inc." -50R389,RCF,33,Cherry Park Plaza,1323 SW Cherry Park Road,"Troutdale, OR 97060",,"CHGCXA Troutdale, LLC","CHG Management Company I, LLC" -50R390,RCF,56,Mt. Bachelor Memory Care,20225 Powers Road,"Bend, OR 97702",,"MBMC 1, LLC","Frontier Management, LLC" -50R391,RCF,10,Wallowa Valley Senior Living Memory Care,605 Medical Parkway,"Enterprise, OR 97828",,Wallowa County Health Care District,"Marathon Enterprise, LLC" -50R393,RCF,27,Jennings McCall RCF,2300 Masonic Way,"Forest Grove, OR 97116",,Grand Lodge of AF & AM of Oregon,"Aidan Health Services, Inc." -50R394,RCF,10,Valley View Memory Care,112 Valley View Drive,"John Day, OR 97845",,"Valley View Investors, LLC","Ageia Health Services, LLC" -50R395,RCF,28,Four Seasons RCF Evergreen,2855 Evergreen Ave NE,"Salem, OR 97301",,Four Seasons RCF Evergreen,Four Seasons RCF Evergreen -50R396,RCF,39,Whitewood Gardens,2027 SE 174th Ave.,"Portland, OR 97233",,"Whitewood Group, LLC","Whitewood Group, LLC" -50R397,RCF,31,Footsteps at Sherwood,15677 SW Oregon,"Sherwood, OR 97140",,"HSRE-Springs II at Sherwood Sub-TRS, LLC","The Springs Living, LLC" -50R398,RCF,16,Footsteps at Carman Oaks,3900 SW Carman Drive,"Lake Oswego, OR 97035",,"HSRE-Springs II at Lake Oswego Sub-TRS, LLC","The Springs Living, LLC" -50R399,RCF,25,Footsteps at Mill Creek,1021 W 10th Street,"The Dalles, OR 97058",,"HSRE-Springs II at the Dalles, LLP","The Springs Living, LLC" -50R400,RCF,15,Vista View Mood & Memory Care,4439 Hamrick Rd,"Central Point, OR 97502",,Kathleen Howard,Kathleen Howard -50R401,RCF,26,Marie Rose Residential Care,17360 Holy Names Drive,"Lake Oswego, OR 97034",,"Mary's Woods at Marylhurst, Inc.","Mary's Woods at Marylhurst, Inc." -50R402,RCF,18,Grace Manor,2811 Bailey Lane,"Eugene, OR 97401",,"Grace Manor Lease Interests, LL","Senior Housing Managers, LLC" -50R403,RCF,44,Brookdale Geary Street Memory Care,2445 Geary St SE,"Albany, OR 97321",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -50R404,RCF,32,Coral Springs Residential Care,2520 Coral Ave. NE,"Salem, OR 97305",,"Sweet Bye N Bye AFC & RCF Facilities, Inc.","Sweet Bye N Bye AFC & RCF Facilities, Inc." -50R405,RCF,15,Elite Care Oatfield Estates Larch House,4405 SE Oatfield Hill Rd,"Milwaukie, OR 97267",,"Elite Care OE2, LLC","Elite Care OE2, LLC" -50R406,RCF,15,Elite Care Oatfield Estates Tabor House,4425 SE Oatfield Hill Rd,"Milwaukie, OR 97267",,Elite Care OE2 LLC,"Elite Care OE2, LLC" -50R407,RCF,15,Bartlett House of Medford Memory Care Community,3465 Lone Pine Rd,"Medford, OR 97504",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." -50R408,RCF,15,Bee Hive Homes of Baker City,3078 Resort St.,"Baker City, OR 97814",,"The Home Place in Baker, LLC",Bee Hive Homes of Baker City -50R409,RCF,48,Heartwood Place,2325 Boones Ferry Road,"Woodburn, OR 97071",,WMC Operating Company LLC,"Benicia Senior Living, LLC" -50R410,RCF,21,McKenzie Living,"6452 ""A"" Street","Springfield, OR 97478",,"McKenzie Living, Inc.","McKenzie Living, Inc. " -50R411,RCF,64,Waterford Grand Memory Care,600 Waterford Way,"Eugene, OR 97401",,"BDC/EUGENE, LLC",BPM Senior Living Company -50R412,RCF,16,Sunset Estates,281 Sunset Dr.,"Ontario, OR 97914",,"CARE 3, LLC","CARE 3, LLC" -50R413,RCF,38,Parkview Memory Care at Cherrywood Village,10721 SE Cherry Blossom Dr.,"Portland, OR 97216",,"PAR, LLC","PAR, LLC" -50R414,RCF,48,"Arbor at Avamere Court, The",450 Claggett Court N,"Keizer, OR 97303",,"Keizer River Operations, LLC","Keizer River Operations, LLC" -50R416,RCF,56,"Cherrywood Memory Care, The",2750 NE Doran Drive,"McMinnville, OR 97128",,"Cherrywood, Inc., The","Cherrywood, Inc., The" -50R417,RCF,34,Advocate Care,13033 South East Holgate Blvd,"Portland, OR 97236",,"Advocate Care, LLC","Advocate Care, LLC" -50R418,RCF,64,Windsong at Eola Hills,2030 Wallace Road NW,"Salem, OR 97304",,"West Salem Memory Care, LLC","Aidan Health Services, Inc." -50R421,RCF,32,Clatsop Care Memory Community,2219 SE Dolphin Road,"Warrenton, OR 97146",,Clatsop Care Center Health District,Clatsop Care Center Health District -50R430,RCF,23,Bonaventure of Albany Memory Care,420 Geri Street,"Albany, OR 97321",,Mountain West Retirement Corporation,Bonaventure Senior Living -50R432,RCF,23,Bonaventure of Tigard Memory Care,15000 SW Hall Blvd,"Tigard, OR 97224",,"Bonaventure of Tigard, LLC",Bonaventure Senior Living -50R433,RCF,68,Waterhouse Ridge Memory Care Community,1115 NW 158th Avenue,"Beaverton, OR 97006",,"Waterhouse Ridge Memory Care, LLC",Frontline Management -5MA003,RCF,40,Ashley Manor - Sage,1355 SW Sage,"Hermiston, OR 97838",,"Ashley Manor, LLC","Ashley Manor, L.L.C." -5MA016,RCF,15,Clarendon Court Alzheimer's Residence,5732 SE 122nd Ave,"Portland, OR 97236",,"Clarendon Court Alzheimer's Residence, LLC","Clarendon Court Alzheimer's Residence, LLC" -5MA024,RCF,62,Curry Manor,1458 Quail Lane,"Roseburg, OR 97470",,"TSL Curry Manor, LLC","Tierra Senior Living, LLC" -5MA031,RCF,76,Farmington Square - Gresham,1655 NE 18th,"Gresham, OR 97030",,"RSL Gresham, LLC","Radiant Senior Living, Inc." -5MA042,RCF,130,Gateway Living,611 N Cloverleaf Loop,"Springfield, OR 97477",,"Gateway Assisted Living, Inc","Gateway Assisted Living, Inc." -5MA043,RCF,102,Providence ElderPlace in Glendoveer,13007 NE Glisan St,"Portland, OR 97230",,Providence Health & Services - Oregon,Providence Health & Services - Oregon -5MA051,RCF,40,Harvest Homes RCF,6921 N Roberts,"Portland, OR 97203",,"Harvest Homes, Inc.","Harvest Homes, Inc." -5MA080,RCF,28,Lydia's House,5353 SE Columbus St,"Albany, OR 97321",,"Mennonite Home Of Albany, Inc.","Mennonite Home Of Albany, Inc." -5MA106,RCF,65,Southtowne Living Center,360 W 28th,"Eugene, OR 97405",,"Eugene Southtowne Living Center, LLC","Ageia Health Services, LLC" -5MA107,RCF,85,St. Andrews Memory Care,7617 SE Main St,"Portland, OR 97215",,"Pacifica Senior Living, LLC","Pacifica Senior Living, LLC" -5MA130,RCF,15,Brookdale McMinnville City Center Memory Care,721 NE 27th St.,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -5MA131,RCF,48,Pelican Pointe Memory Care Community,615 Washburn Way,"Klamath Falls, OR 97603",,"ARHC PPKLAOR01 TRS, LLC","FM Pelican, LLC" -5MA137,RCF,30,Pacific View Memory Care Community,1000 6th Ave West,"Bandon, OR 97411",,"Bandon Senior Living, LLC","Seasons Management, LLC" -5MA146,RCF,110,Brookdale Forest Grove,3110 19th Ave,"Forest Grove, OR 97116",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -5MA151,RCF,57,Brookstone Alzheimer's Special Care Center,5881 SE Woodside Dr,"Salem, OR 97301",,Salem Associates LLC,"Jerry Erwin Associates, Inc." -5MA160,RCF,114,Pacifica Senior Living Portland,1808 SE 182nd Ave,"Portland, OR 97233",,"Pacifica Senior Living, LLC","Pacifica Senior Living, LLC" -5MA161,RCF,32,Skylark Memory Care,950 Skylark Place,"Ashland, OR 97520",,"Ashland Assisted Living, LLC","Mission Senior Living, LLC" -5MA162,RCF,50,"Atrium at McLoughlin Place, The",1153 Molalla Ave,"Oregon City, OR 97045",,"McLoughlin Place Operations, LLC","Milestone Retirement Communities, LLC" -5MA166,RCF,14,Ashley Manor - Alameda,1310 SW 12th Ave,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -5MA170,RCF,37,Brookdale McMinnville Westside,320 SW Hill Road,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -5MA205,RCF,60,Brookdale Salem,1355 Boone Rd SE,"Salem, OR 97302",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -5MA206,RCF,10,Ashley Manor - Well Springs,2110 SW 2nd Avenue,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -5MA207,RCF,56,Cedar Crest Alzheimer Special Care,18325 SW Pacific HWY,"Tualatin, OR 97062",,"Tualatin Associates, LLC",JEA Senior Living -5MA213,RCF,42,Powell Valley Memory Care Community,4001 SE 182nd Ave,"Gresham, OR 97030",,PVALC-LLC,"Care Wise Management, Inc." -5MA215,RCF,55,Baycrest Memory Care,955 Kentucky Avenue,"Coos Bay, OR 97420",,"Bay Area Properties, LLC","Radiant Senior Living, Inc." -5MA217,RCF,51,Footsteps at The Wilsonville,7600 Vlahos Drive,"Wilsonville, OR 97070",,"HSRE-Springs at Wilsonville Sub-TRS, LLC","The Springs Living, LLC" -5MA221,RCF,42,Aspen Ridge Memory Care,1025 NE Purcell Blvd,"Bend, OR 97701",,"FM Aspen MC, LLC","Frontier Management, LLC" -5MA222,RCF,55,Ocean Park,984 Parkview Drive,"Brookings, OR 97415",,"ARHC OPBROOR01 TRS, LLC",Ocean Park Care Properties -5MA223,RCF,60,Pacific Gardens Alzheimer's Special Care Center,17309 NE Glisan,"Portland, OR 97230",,"Erwin Family Properties II, LLC",JEA Senior Living -5MA233,RCF,30,Ashley Manor - Roseburg,427 SE Ramp St.,"Roseburg, OR 97470",,Ashley Manor LLC,Ashley Manor LLC -5MA238,RCF,15,Ashley Manor - Meadow Lakes,228 SW Meadow Lakes Drive,"Prineville, OR 97754",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -5MA240,RCF,48,Callahan Court Memory Care Comm.,1770 NW Valley View Drive,"Roseburg, OR 97470",,LSREF Golden Ops 14(OR) LLC,"Frontier Management, LLC" -5MA241,RCF,15,Ashley Manor - Oak,572 NE Oak Street,"Madras, OR 97741",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -5MA242,RCF,56,"Gardens Enhanced Care Community, The",3334 22nd Ave,"Forest Grove, OR 97116",,"The Grove Assisted Living, L.L.C.","Heights Management, Inc." -5MA243,RCF,79,Quail Park Memory Care Residences,2630 Lone Oak Way,"Eugene, OR 97404",,"Laurel Court of Eugene, LLC",Living Care Management -5MA245,RCF,24,Avamere at Sherwood,16500 SW Century Drive,"Sherwood, OR 97140",,"Avamere Sherwood Operations, LLC","Avamere-Sherwood Operations, LLC" -5MA246,RCF,14,Ashley Manor - Brookhurst,2146 Brookhurst,"Medford, OR 97504",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -5MA249,RCF,24,Avamere at Sandy,17727 SE Langensand Rd,"Sandy, OR 97055",,"Avamere-Sandy Operations, LLC","Avamere Sandy Operations, LLC" -5MA252,RCF,24,Courtyard at Mt.Tabor Garden House,6323 SE Division,"Portland, OR 97206",,"Courtyard Assisted Members, LLC","Integral Senior Living, LLC" -5MA254,RCF,60,Brookdale Roseburg,3400 NW Edenbower Blvd.,"Roseburg, OR 97470",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -5MA255,RCF,15,Ashley Manor - Heidi Lane,2144 NW Heidi Lane,"Grants Pass, OR 97526",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." -5MA259,RCF,22,Avamere at Newberg,730 Foothills Dr.,"Newberg, OR 97132",,"Genesis Newberg Operations Company, LLC","Genesis Newberg Operations Company, LLC" -5MA261,RCF,24,Avamere at Hillsboro,2000 SE 30th Avenue,"Hillsboro, OR 97123",,"Avamere-Hillsboro Operations, LLC","Avamere-Hillsboro Operations, LLC" -5MA266,RCF,30,Wildflower Lodge,508 16th St,"LaGrande, OR 97850",,LSREF Golden Ops 14 (OR) LLC,"SLH Rainier Manager, LLC" -5MA269,RCF,64,Brookdale Grants Pass Pointe,1400 Redwood Circle,"Grants Pass, OR 97527",,"S-H OpCo Spring Pointe, LLC","Brookdale Senior Living Communities, Inc." -5ME119,RCF,95,ElderHealth & Living,382-B South 58th St,"Springfield, OR 97478",,ElderHealth & Living Corporation,ElderHealth & Living Corporation -5ME175,RCF,16,Premier Living Center,5120 SE 118th,"Portland, OR 97266",,"Premier Living Center, Inc.","Premier Living Center, Inc." -5ME248,RCF,16,Harmony Living,1535 SW Shirley Ann Drive,"McMinnville, OR 97128",,"Harmony Living, Inc.","Harmony Living, Inc." -70A011,ALF,105,Canfield Place Retirement Community,14570 SW Hart Rd,"Beaverton, OR 97005",,Canfield Place Rtrmt Comm LLC,"Leisure Care, LLC" -70A012,ALF,21,"Springs at Carman Oaks, The",3900 SW Carman Dr,"Lake Oswego, OR 97035",,"HSRE-Springs II at Lake Oswego Sub-TRS, LLC","The Springs Living, LLC" -70A057,ALF,63,Markham House Retirement Community,10606 SW Capitol Hwy,"Portland, OR 97219",,"PORTMH, LLC","Leisure Care, LLC" -70A062,ALF,45,Brookdale Ashland,548 North Main Street,"Ashland, OR 97520",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A069,ALF,55,Regency Park Place at Corvallis,2595 Jack London St,"Corvallis, OR 97330",,"BD Corvallis I, LLC","Regency Pacific Management, LLC" -70A083,ALF,108,"Sheldon Park Assisted Living, a Blue Harbor Senior Living Community",2440 Willakenzie Road,"Eugene, OR 97401",,Sheldon Park Management LLC,Sheldon Park Management LLC -70A097,ALF,70,Timberhill Place,989 NW Spruce Ave,"Corvallis, OR 97330",,"Vintage Investment Prop., Inc.","Vintage Investment Prop., Inc." -70A102,ALF,38,Well Springs Assisted Living Facility,2104 W Idaho,"Ontario, OR 97914",,C & I Properties LLC,"Milestone Retirement Communities, LLC" -70A200,ALF,85,"Springs at Wilsonville, The",7600 Vlahos Drive,"Wilsonville, OR 97070",,"HSRE-Springs II at Lake Oswego Sub-TRS, LLC","The Springs Living, LLC" -70A209,ALF,64,"Terrace at Laurelhurst Village, The",3120 SE Stark,"Portland, OR 97214",,"Laurelhurst Operations, LLC","Laurelhurst Operations, LLC" -70A214,ALF,147,Jennings - McCall Center,2300 Masonic Way,"Forest Grove, OR 97116",,Grand Lodge of AF & AM of Oregon,"Aidan Health Services, Inc." -70A235,ALF,60,Bonaventure of Albany Assisted Living,420 Geri Street,"Albany, OR 97321",,Mountain West Retirement Corporation,Bonaventure Senior Living -70A246,ALF,64,Terwilliger Terrace Assisted Living Facility,2425 SW 6th Ave.,"Portland, OR 97201",,"Terwilliger Plaza, Inc.","Terwilliger Plaza, Inc." -70A249,ALF,20,Providence Brookside Manor,1550 Brookside Dr.,"Hood River, OR 97031",,Providence Health & Services - Oregon,Providence Health System - Oregon -70A259,ALF,50,Willamette View Neighborhoods,13145 SE River Road,"Portland, OR 97222",,"Willamette View, Inc. dba","Willamette View, Inc." -70A260,ALF,72,Prestige Senior Living Southern Hills,4795 Skyline Rd. S.,"Salem, OR 97306",,CHP Salem-Southern Hills OR Tenant Corp.,"Prestige Senior Living, L.L.C" -70A261,ALF,59,Edgewood Point Assisted Living,7733 SW Scholls Ferry Rd,"Beaverton, OR 97008",,"Beaverton Assisted Living, LLC","Hawthorn Retirement Group, LLC" -70A262,ALF,68,Terrace at Hillside Assisted Living,440 NW Hillside Park Way,"McMinnville, OR 97128",,Emeritus Corporation,Emeritus Corporation -70A263,ALF,53,Shore Pines Assisted Living,93975 Ocean Way,"Gold Beach, OR 97444",,"Shore Pines Assisted Living, LLC","Mosaic Management, Inc." -70A264,ALF,110,Royal Anne Assisted Living Facility,10610 SE Clay St.,"Portland, OR 97216",,"PAR, LLC","Generations, LLC" -70A265,ALF,50,Sea Aire Assisted Living,1882 N Hwy 101,"Yachats, OR 97498",,"Sea Aire Assisted Living, LLC","Sea Aire Assisted Living, LLC" -70A266,ALF,77,"Bridge Assisted Living, The",201 SW Bridge St.,"Grants Pass, OR 97526",,"Grants Pass Assisted Living, LLC","Woollard Ipsen Management, LLC" -70A267,ALF,96,Vineyard Heights Assisted Living & Retirement Cottages,345 SW Hill Rd.,"McMinnville, OR 97128",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" -70A268,ALF,90,Raleigh Hills Assisted Living Community,4815 SW Dogwood Ln,"Portland, OR 97225",,"Raleigh Hills Management, LLC","Raleigh Hills Management, LLC" -70A269,ALF,85,Hawks Ridge Senior Assisted Living Community,1795 8th St,"Hood River, OR 97031",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" -70A270,ALF,100,Somerset Assisted Living,8360 Cason Rd,"Gladstone, OR 97027",,Gladstone Assisted Living LLC,"Hawthorn Retirement Group, LLC" -70A271,ALF,130,Providence ElderPlace in Irvington Village,420 NE Mason,"Portland, OR 97211",,Providence Health & Services - Oregon,Providence Health & Services - Oregon -70A273,ALF,80,Hearthstone at Murrayhill Assisted Living,10880 SW Davies Rd,"Beaverton, OR 97008",,"Hearthstone at Murrayhill, LLC","Hearthstone Management Services, LLC" -70A274,ALF,95,Stoneybrook Assisted Living,4650 SW Hollyhock Circle,"Corvallis, OR 97333",,"Corvallis Assisted Living, LLC","Hawthorn Retirement Group, LLC" -70A275,ALF,64,Avamere at Seaside,2500 S. Roosevelt Dr.,"Seaside, OR 97138",,"Necanicum Operations, LLC","Necanicum Operations, LLC" -70A276,ALF,57,"Springs at Sherwood, The",15677 SW Oregon,"Sherwood, OR 97140",,"HSRE-Springs at Sherwood Sub-TRS, LLC","The Springs Living, LLC" -70A277,ALF,67,Prestige Senior Living Orchard Heights,695 Orchard Heights Rd NW,"Salem, OR 97304",,CHP Salem -Orchard Heights OR Tenant Corp,"Prestige Senior Living, LLC" -70A278,ALF,84,Assumption Village,9121 N. Burr Avenue,"Portland, OR 97203",,Assumption Village LLC,S.A.G.E. -70A279,ALF,82,Prestige Senior Living Five Rivers,3500 12th St,"Tillamook, OR 97141",,CHP Tillamook-Five Rivers OR Tenant Corp,"Prestige Senior Living, LLC" -70A280,ALF,55,Corvallis Caring Place Assisted Living,750 NW 23rd St,"Corvallis, OR 97330",,"Corvallis Caring Place, Inc.","Mennonite Management Services, Inc." -70A281,ALF,72,Prestige Senior Living West Hills,5595 SW West Hills Rd.,"Corvallis, OR 97333",,"CHP-Corvallis-West Hills OR Tenant, Inc.",Prestige Senior Living -70A283,ALF,18,Willow Creek Terrace,400 Frank Gilliam Dr.,"Heppner, OR 97836",,Willow Creek Valley Assisted Living Corp.,Morrow County Health District -70A284,ALF,85,SpringRidge Court Assisted Living,32100 SW French Prairie Rd.,"Wilsonville, OR 97070",,Spring Ridge Subtenant LLC,"SRG Management, LLC" -70A285,ALF,50,Country Meadows Village,155 S. Evergreen,"Woodburn, OR 97071",,"Crown II Development, LLC","Crown Two Development, LLC" -70A286,ALF,72,Marquis Wilsonville Assisted Living,30900 SW Parkway Ave,"Wilsonville, OR 97070",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -70A287,ALF,40,"Amber Assisted Living, The",365 SW Bel Air Drive- PO Box 308,"Clatskanie, OR 97016",,"Amber Investors, LLC","Ageia Health Services, LLC" -70A288,ALF,80,Marquis Piedmont Assisted Living,319 NE Russet St.,"Portland, OR 97211",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -70A289,ALF,75,Prestige Senior Living High Desert,2660 NE Mary Rose Place,"Bend, OR 97701",,CHP Bend-High Desert OR Tenant Corp.,"Prestige Senior Living, LLC" -70A290,ALF,78,Brookdale Chestnut Lane - Gresham,1219 NE Sixth Street,"Gresham, OR 97030",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A291,ALF,90,Avamere at Bethany Assisted Living Facility,16360 NW Avamere Court,"Portland, OR 97229",,"Avamere Bethany Operations, LLC","Avamere-Bethany Operations, LLC" -70A292,ALF,64,Prestige Senior Living Arbor Place,3150 Juanipero Way,"Medford, OR 97504",,CHP Medford -Arbor Place OR Tenant Corp.,"Prestige Senior Living, LLC" -70A293,ALF,31,Pioneer Place Assisted Living,1060 D Street W,"Vale, OR 97918",,Pioneer Nursing Home Health District,Pioneer Nursing Home Health District -70A294,ALF,76,Fox Hollow Independent & Assisted Living Community,2599 NE Studio Rd,"Bend, OR 97701",,"Fox Hollow Bend, LLC","Regency Pacific Management, LLC" -70A295,ALF,100,Brookdale Sellwood,8517 SE 17th Avenue,"Portland, OR 97202",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A296,ALF,35,Canyon Rim Manor,1701 George Jackson Rd.,"Maupin, OR 97037",,"Maupin Senior Living, LLC","Mosaic Management, Inc." -70A297,ALF,95,Brookdale Lebanon,181 South 5th Street,"Lebanon, OR 97355",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A298,ALF,60,Pioneer Village,805 N. 5th St.,"Jacksonville, OR 97530",,"RSL Pioneer, LLC","Radiant Senior Living, Inc." -70A299,ALF,150,Brookdale Springfield Briarwood,4865 Main Street,"Springfield, OR 97478",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A300,ALF,44,"Springs at Veranda Park, The",1641 NE Veranda Park Drive,"Medford, OR 97504",,"HSRE-Springs III at Medford VP Sub TRS, LLC","The Springs Living, LLC" -70A301,ALF,69,Bonaventure of Tigard Assisted Living,15000 SW Hall Blvd,"Tigard, OR 97224",,"Bonaventure of Tigard, LLC",Bonaventure Senior Living -70A302,ALF,100,Ocean Ridge Retirement and Assisted Living Community,1855 SE Ocean Blvd.,"Coos Bay, OR 97420",,"ARHC ORCOOOR01 TRS, LLC","FM Ocean Ridge, LLC" -70A303,ALF,82,Brookdale Oswego Springs - Portland,11552 SW Lesser Rd.,"Portland, OR 97219",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A304,ALF,79,Oswego Place Assisted Living Community,17450 Pilkington Rd.,"Lake Oswego, OR 97035",,"Oswego Place Assisted Living Community, LLC",Bonaventure Senior Living -70A305,ALF,77,Brookdale Redmond Assisted Living,1942 SW Canyon Drive,"Redmond, OR 97756",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A306,ALF,85,Middlefield Oaks Assisted Living Community,1500 Village Drive,"Cottage Grove, OR 97424",,"Middlefield Oaks Assisted Living, LLC",Fronline Management -70A307,ALF,62,Bayberry Commons Assisted Living,2211 Laura Street,"Springfield, OR 97477",,"Bayberry Commons, Inc.",Ridgeline Management Co. -70A308,ALF,110,Brookdale Newberg,3802 Hayes St.,"Newberg, OR 97132",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70A309,ALF,65,Hawthorne Gardens Senior Living Community,2828 SE Taylor Street,"Portland, OR 97214",,"GF Hawthorne Tenant, LLC","Artegan at Hawthorne Gardens, LLC" -70A310,ALF,16,"Stafford Assisted Living Facility, The",1200 Overlook Dr,"Lake Oswego, OR 97034",,"Avamere Stafford Operations, LLC","Avamere Stafford Operations, LLC" -70A311,ALF,29,Fircrest Community Living,213 NE Fircrest Drive,"McMinnville, OR 97128",,"Fircrest Community Living, Inc.","Fircrest Community Living, Inc." -70A312,ALF,153,Laurel Parc at Bethany,15850 NW Central Drive,"Portland, OR 97229",,"Laurel Parc AL at Bethany, LLC","Laurel Parc AL at Bethany, LLC" -70A314,ALF,120,Russellville Park West,23 SE 103rd,"Portland, OR 97216",,"Russellvillle III, LLC","Leisure Care, LLC" -70A315,ALF,49,Courtyard Fountains Assisted Living Community,1537 SE 223rd,"Gresham, OR 97030",,"ARHC CFGREOR01 TRS, LLC","Courtyard Fountains Care Properties, LLC" -70A316,ALF,99,Sea View Senior Living Community,98059 Gerlach Lane,"Brookings, OR 97415",,"Sea View Assisted Living Community, LLC","Seasons Management, LLC" -70A317,ALF,24,Mirabella at South Waterfront,3550 SW Bond Ave.,"Portland, OR 97239",,Mirabella at South Waterfront,"Pacific Retirement Services, Inc." -70A318,ALF,22,Countryside Village,1700 Kellenbeck Rd.,"Grants Pass, OR 97528",,"Lynn-Ann Development, LLC","Lynn-Ann Development, LLC" -70A319,ALF,64,Royalton Place Assisted Living,5555 SE King Rd,"Milwaukie, OR 97222",,"BDC/Milwaukie, LLC","Royalton Place Management, LLC" -70A320,ALF,65,Bonaventure of Salem Assisted Living,3411 Boone Rd SE,"Salem, OR 97317",,"Bonaventure of Salem, LLC",Bonaventure Senior Living -70A321,ALF,25,Dallas Retirement Village Assisted Living HUD,377 NW Jasper St,"Dallas, OR 97338",,"Dallas Health Care Center, LLC",Life Care Services -70A322,ALF,19,Wallowa Valley Senior Living,605 Medical Parkway,"Enterprise, OR 97828",,Wallowa County Health Care District,"Marathon Enterprise, LLC" -70A323,ALF,101,Waterford Grand Assisted Living,600 Waterford Way,"Eugene, OR 97401",,"BDC/EUGENE, LLC",BPM Senior Living Company -70A324,ALF,87,Marquis Tualatin Assisted Living,19945 SW Boones Ferry Road,"Tualatin, OR 97062",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -70M001,ALF,40,Adams House Assisted Living,121 Cordelia Drive,"Myrtle Creek, OR 97457",,"Assisted Living Facilities, Inc.","Concepts in Community Living, Inc." -70M002,ALF,64,Alderwood Assisted Living,131 Alder St,"Central Point, OR 97502",,"Alderwood Assisted Living, LLC","AIM Senior Management, LLC" -70M003,ALF,36,Alpine House Assisted Living,204 N Park St,"Joseph, OR 97846",,"Joseph ALF, Inc.","Joseph ALF, Inc." -70M004,ALF,12,Chinook Place,470 NE Oak St,"Madras, OR 97741",,"ASPEN COURT AID OPCO, LLC","ASPEN COURT AID OPCO, LLC" -70M005,ALF,48,Aspens (The),210 Roe Davis Ave,"Hines, OR 97738",,"Harney Pioneer Homes, Inc","Concepts in Community Living, Inc." -70M006,ALF,96,Summerplace Assisted Living Community,15727 NE Russell St,"Portland, OR 97230",,"Summerplace Assisted Living, LLC","Prestige Senior Living, LLC" -70M007,ALF,34,Astor Place,999 Klaskanine Ave,"Astoria, OR 97103",,"ASTOR AID OPCO, LLC","ASTOR AID OPCO, LLC" -70M008,ALF,49,Awbrey Place,2825 Neff Rd,"Bend, OR 97701",,"AWBREY AID OPCO, LLC","AWBREY AID OPCO, LLC" -70M009,ALF,50,Bridgewood Rivers Assisted Living,1901 NW Hughwood,"Roseburg, OR 97470",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M010,ALF,45,Brookside Place,3550 SW Canal Blvd,"Redmond, OR 97756",,"Redmond ALF, Inc.","Concepts in Community Living, Inc." -70M013,ALF,34,Carriage Place,150 S Williamson Dr,"Prineville, OR 97754",,"CARRIAGE AID OPCO, LLC","CARRIAGE AID OPCO, LLC" -70M014,ALF,48,Churchill Estates Assisted Living,1919 Bailey Hill Rd,"Eugene, OR 97405",,"Churchill Management, Inc.","Churchill Retirement Services, LLC" -70M015,ALF,75,Cornell Estates Retirement and Assisted Living Residence,1005 NE 17th,"Hillsboro, OR 97123",,Cornell Investors Group Inc.,"Cornell Investors Group, Inc." -70M016,ALF,80,Brookdale Geary Street,2445 Geary St SE,"Albany, OR 97321",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -70M017,ALF,50,Brookdale McMinnville City Center,721 NE 27th St.,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." -70M018,ALF,53,Dallas Retirement Village Assisted Living,340 NW Brentwood St,"Dallas, OR 97338",,"Dallas Mennonite Retirement Community, Inc.",Life Care Services -70M019,ALF,36,Davenport Place,930 Oak St,"Silverton, OR 97381",,"DAVENPORT AID OPCO, LLC","DAVENPORT AID OPCO, LLC" -70M020,ALF,48,Deerfield Village Assisted Living,5770 SE Kellogg Cr Dr,"Milwaukie, OR 97222",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M021,ALF,50,Dorian Place Assisted Living Facility,375 N Dorian Dr,"Ontario, OR 97914",,"Dorian Place Operations, LLC","Milestone Retirement Communities, LLC" -70M022,ALF,36,Applegate Place,1465 East Central,"Sutherlin, OR 97479",,"Sutherlin ALF, Inc.","Concepts in Community Living, Inc." -70M023,ALF,77,Parkview Assisted Living,10801 NE Weidler,"Portland, OR 97220",,Oregon Baptist Retirement Home,Oregon Baptist Retirement Homes -70M024,ALF,70,Brookdale at Klamath Falls,2130 Eldorado Blvd,"Klamath Falls, OR 97601",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M025,ALF,60,Elliott Residence,390 Church St,"Sublimity, OR 97385",,"Janmaur I, L.L.C.",Marian Estates Support Services -70M026,ALF,48,Emerald Valley Assisted Living,4550 W Amazon Dr,"Eugene, OR 97405",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M027,ALF,44,Oregon Retirement Center,1010 NE 3rd,"Milton-Freewater, OR 97862",,"Evergreen Oregon Healthcare Orchards Retirement, LLC","Evergreen Healthcare Management, LLC" -70M028,ALF,60,Flagstone Retirement & Assisted Living,3325 Columbia View Dr.,"The Dalles, OR 97058",,"Flagstone Operations, LLC.","Milestone Retirement Communities, LLC" -70M029,ALF,48,Forest Grove Beehive,2122 Hawthorne,"Forest Grove, OR 97116",,"Forest Grove Beehive, LLC","Caring Places Management, LLC" -70M030,ALF,65,Gibson Creek Retirement & Assisted Living Residence,1615 Brush College Rd NW,"Salem, OR 97304",,"TLC West, L.L.C.",Bonaventure Senior Living -70M031,ALF,101,Gilman Park Assisted Living,2205 Gilman Drive,"Oregon City, OR 97045",,"FM Gilman, LLC","Frontier Management, LLC" -70M032,ALF,36,Grace Place,380 NW 6th Ave,"Estacada, OR 97023",,"GRACE AID OPCO, LLC","GRACE AID OPCO, LLC" -70M033,ALF,76,Grande Ronde Retirement Residence,1809 Gekeler Lane,"La Grande, OR 97850",,"FM Grande, LLC","Frontier Management, LLC" -70M034,ALF,79,Greenridge Estates At Mountain Park,4 Greenridge Dr,"Lake Oswego, OR 97035",,"Greenridge Estates at Mountain Park, LLC","Greenridge Estates at Mountain Park, LLC" -70M035,ALF,78,"Grove Assisted Living, The",2112 Oak St,"Forest Grove, OR 97116",,"The Grove Assisted Living, L.L.C.","Heights Management, Inc." -70M036,ALF,49,Harvest Homes,6921 N Roberts Ave,"Portland, OR 97203",,"Harvest Homes, Inc.","Harvest Homes, Inc." -70M037,ALF,75,Hearthstone Of Beaverton,12520 SW Hart Rd,"Beaverton, OR 97008",,"Hearthstone of Beaverton Operations, LLC","Hearthstone Management Services, LLC" -70M038,ALF,55,Regency Village at Redmond,3000 SW 32nd St,"Redmond, OR 97756",,"BD Redmond I, LLC","Regency Pacific Management, LLC" -70M039,ALF,85,Pacific View Assisted Living Community,1000 6th Ave West,"Bandon, OR 97411",,"Bandon Senior Living, LLC","Seasons Management, LLC" -70M040,ALF,63,Brookdale Hermiston,980 W Highland Ave,"Hermiston, OR 97838",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M041,ALF,37,Hillside Place,1400 SE 19th,"Lincoln City, OR 97367",,"HILLSIDE AID OPCO, LLC","HiLLSIDE AID OPCO, LLC" -70M042,ALF,52,Homewood Heights Assisted Living,17999 SE River Rd,"Milwaukie, OR 97267",,Homewoods Heights LLC,"Prestige Senior Living, L.L.C" -70M043,ALF,30,Willow Place,1307 N College,"Newberg, OR 97132",,"Assisted Living Facilities, Inc.","Concepts in Community Living, Inc." -70M044,ALF,60,Inland Point Retirement Community,2290 Inland Dr,"North Bend, OR 97459",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M045,ALF,40,Suncrest Place,300 Suncrest Rd,"Talent, OR 97540",,"JACKSON AID OPCO, LLC","JACKSON AID OPCO, LLC" -70M048,ALF,36,Junction City Retirement & Assisted Living Residence,500 E 6th St,"Junction City, OR 97448",,"FC Ranger OPS Junction City (OR), LLC","Frontier Management, LLC" -70M049,ALF,31,Juniper House,301 SW 28th Dr,"Pendleton, OR 97801",,"Assisted Living Facilities, Inc.","Concepts in Community Living, Inc." -70M050,ALF,36,Kilchis House,4212 Marolf Place,"Tillamook, OR 97141",,"Tillamook County CARE, Inc.","Tillamook County CARE, Inc." -70M051,ALF,50,Lancaster Assisted Living,4156 Market St NE,"Salem, OR 97301",,Lancaster Assisted Living LLC,"Senior Living Management, Inc." -70M052,ALF,36,Lancaster Village,4148 Market St NE,"Salem, OR 97301",,"Lancaster Village, LLC","Senior Living Services, Inc." -70M053,ALF,67,Lakeview Senior Living,2690 NE Yacht,"Lincoln City, OR 97367",,"Lakeview Operations, LLC","Westmont Living, Inc." -70M054,ALF,43,Rogue River Place,2437 Kane St,"Klamath Falls, OR 97603",,"Sage AID OPCO, LLC","Sage AID OPCO, LLC" -70M055,ALF,42,Macklyn Place,755 Elk Drive,"Brookings, OR 97415",,"MACKLYN AID OPCO, LLC","MACKLYN AID OPCO, LLC" -70M056,ALF,56,Magnolia Gardens Assisted Retirement Living,1425 Daugherty,"Cottage Grove, OR 97424",,Magnolia Gardens Assisted Retirement Living LLC,Magnolia Gardens L.L.C. -70M058,ALF,60,McKillop Residence,500 Conifer Circle,"Sublimity, OR 97385",,"Janmaur II, L.L.C.",Marian Estates Support Services -70M059,ALF,74,McLoughlin Place Senior Living,1153 Molalla Ave,"Oregon City, OR 97045",,"McLoughlin Place Operations, LLC","Milestone Retirement Communities, LLC" -70M060,ALF,52,Meadow Creek Village Assisted Living,3988 12th St SE,"Salem, OR 97302",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M061,ALF,60,Meadowbrook Place,4000 Cedar St,"Baker City, OR 97814",,"Meadowbrook Place Operations, LLC","Concepts in Community Living, Inc." -70M063,ALF,25,"Gardens at Laurelhurst Village, The",3060 SE Stark St,"Portland, OR 97214",,"Laurelhurst Operations, LLC","Laurelhurst Operations, LLC" -70M064,ALF,48,Neawanna By The Sea,20 North Wahanna Rd,"Seaside, OR 97138",,"FC Ranger OPS Neawanna (OR), LLC","Neawanna Care Properties, LLC" -70M065,ALF,44,Nehalem Bay House,35385 Tohl Ave,"Nehalem, OR 97131",,"Tillamook County CARE, Inc.","Tillamook County CARE, Inc." -70M066,ALF,61,Northridge Center,3737 S Pacific Hwy,"Medford, OR 97501",,"Northridge Center, Inc.","Northridge Center, Inc." -70M067,ALF,57,Bayside Terrace Assisted Living,192 Norman Ave,"Coos Bay, OR 97420",,"ARHC OCCOOOR01 TRS, LLC","FM Ocean Crest, LLC" -70M068,ALF,84,Oceanview Assisted Living Residence,525 NE 71st,"Newport, OR 97365",,"Newport Assisted Living, LLC","Westmont Living, Inc." -70M070,ALF,130,Brookdale Park Place - Tigard,8445 SW Hemlock St,"Portland, OR 97223",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M071,ALF,35,Parkhurst Place,2450 May St,"Hood River, OR 97031",,"PARKHURST AID OPCO, LLC","PARKHURST AID OPCO, LLC" -70M072,ALF,60,Parkland Village Retirement Community,3121 NE Cumulus Avenue,"McMinnville, OR 97128",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M073,ALF,115,Powell Valley Assisted Living Community,4001 SE 182nd Ave,"Gresham, OR 97030",,PVALC-LLC,"Care Wise Management, Inc." -70M074,ALF,137,Quail Run Assisted Living,2525 47th Ave SE,"Albany, OR 97321",,"Mennonite Home Of Albany, Inc.","Mennonite Home Of Albany, Inc." -70M075,ALF,29,Rackleff Place,655 SW 13th Ave,"Canby, OR 97013",,"Canby ALF, Inc.","Concepts in Community Living, Inc." -70M076,ALF,95,Redwood Heights Retirement & Assisted Living Community,4050 12th St Cutoff SE,"Salem, OR 97302",,"ARHC RHSALOR01 TRS, LLC","FM Redwood Heights, LLC" -70M077,ALF,118,Regency Park Assisted Living,8300 SW Barnes Rd,"Portland, OR 97225",,Regency Park Apartments Ltd Part.,"Regency Park Management, LLC" -70M078,ALF,56,Brookdale River Road,592 Bever Dr NE,"Keizer, OR 97303",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M079,ALF,40,Guardian Angel Homes,540 NW 12th St,"Hermiston, OR 97838",,"Hermiston Senior Care, LLC","Tailored Management Services, LLC" -70M080,ALF,180,Rose Schnitzer Manor,6140 SW Boundary St,"Portland, OR 97221",,Robison Jewish Home,Robison Jewish Home -70M081,ALF,95,Rosewood Park Retirement & Assisted Living Residence,2405 SE Century Blvd.,"Hillsboro, OR 97123",,"Rosewood Investors Group, L.L.C.","Rosewood ALF, LLC" -70M082,ALF,56,River Run Place,1155 Darlene Lane,"Eugene, OR 97401",,"River Run AID OPCO, LLC","River Run AID OPCO, LLC" -70M084,ALF,41,Silver Creek Assisted Living Facility,703 Evergreen Rd,"Woodburn, OR 97071",,"FC Ranger OPS Silver Creek (OR), LLC","Silver Creek Care Properties, LLC" -70M085,ALF,87,Skylark Assisted Living,900 Skylark Pl,"Ashland, OR 97520",,"Ashland Assisted Living, LLC","Mission Senior Living, LLC" -70M087,ALF,44,Spring Meadows Assisted Living Facility,36070 Pittsburg Rd,"St Helens, OR 97051",,Elderserv,"Concepts in Community Living, Inc." -70M088,ALF,63,Spring Valley Assisted Living,770 Harlow Rd,"Springfield, OR 97477",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." -70M089,ALF,72,Spruce Point Assisted Living,375 9th St,"Florence, OR 97439",,"Spruce Point, Inc.",Prestige Care Inc. -70M091,ALF,38,Summit Springs Village,133 S Church Street - PO Bx 687,"Condon, OR 97823",,Summit Springs Village Corporation,Summit Springs Village Corporation -70M092,ALF,90,Suzanne Elise Assisted Living Facility,101 Forest Drive,"Seaside, OR 97138",,"Forest Drive Operations, LLC","Forest Drive Operations, LLC" -70M093,ALF,72,Tanner Spring Assisted Living,23000 Horizon Dr,"West Linn, OR 97068",,Sequoia Heights Capital Partners,"TS Management, LLC" -70M094,ALF,87,"Fountains At Town Center Village, The",8607 SE Causey Ave,"Happy Valley, OR 97086",,"TCV Employees, LLC","Generations, LLC" -70M095,ALF,70,"Oaks At Lebanon, The",621 West Oak,"Lebanon, OR 97355",,"FM Oaks, LLC","Frontier Management, LLC" -70M096,ALF,88,Regency Village at Bend,127 SE Wilson Ave,"Bend, OR 97702",,"BD Bend I, LLC","Regency Pacific Management, LLC" -70M098,ALF,42,Valley View Assisted Living,112 Valley View Dr,"John Day, OR 97845",,"Valley View Investors, LLC","Ageia Health Services, LLC" -70M099,ALF,92,Marquis Hope Village ALF,1589 S Ivy,"Canby, OR 97013",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." -70M100,ALF,70,Marquis Forest Grove Assisted Living,3336 19th Ave,"Forest Grove, OR 97116",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." -70M101,ALF,95,"Suites Assisted Living Community, The",1301 SE Parkdale Dr,"Grants Pass, OR 97526",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" -70M103,ALF,60,Wiley Creek Community,5050 Mountain Fir Street,"Sweet Home, OR 97386",,Mid-Valley Healthcare,"Aidan Health Services, Inc." -70M104,ALF,46,Willamette Manor,176 West C Street,"Lebanon, OR 97355",,"Willamette Manor, Inc.","Willamette Manor, Inc." -70M201,ALF,74,Brookdale Monmouth,504 Gwinn St E.,"Monmouth, OR 97361",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M202,ALF,80,Brookdale Eugene Alpine Springs,3760 N. Clarey St.,"Eugene, OR 97402",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M203,ALF,80,Clatsop Retirement Village,947 Olney Ave.,"Astoria, OR 97103",,Clatsop Care Center Health District,Clatsop Care Center Health District -70M204,ALF,56,Springs at Clackamas Woods ALF,14314 SE Webster Rd.,"Milwaukie, OR 97267",,"TSL Clack OPS, LLC","The Springs Living, LLC" -70M205,ALF,54,Providence Benedictine Orchard House,550 S Main St.,"Mt. Angel, OR 97362",,Providence Health & Services - Oregon,Providence Health & Services - Oregon -70M206,ALF,61,Pheasant Pointe Assisted Living Community,835 E. Main Street,"Molalla, OR 97038",,"ARHC PPMOLOR01 TRS, LLC","FM Pheasant Pointe, LLC" -70M207,ALF,57,Regency Village at Prineville,830 North Elm Street,"Prineville, OR 97754",,"BD Prineville I, LLC","Regency Pacific Management, LLC" -70M208,ALF,70,Avamere Living at Newberg,730 Foothills Drive,"Newberg, OR 97132",,"Genesis Newberg Operations Company, LLC","Genesis Newberg Operations Company, LLC" -70M210,ALF,72,Orchards Assisted Living,1018 Royal Court,"Medford, OR 97504",,"Medford Assisted Living, LLC","Woollard Ipsen Management, LLC" -70M211,ALF,74,Prestige Senior Living Riverwood,18321 SW Pacific Hwy,"Tualatin, OR 97062",,CHP Tualatin-Riverwood OR Tenant Corp,"Prestige Senior Living, LLC" -70M212,ALF,48,East Cascade Retirement Community,175 NE 16th Street,"Madras, OR 97741",,"East Cascade Retirement Community, LLC","Senior Housing Managers, LLC" -70M213,ALF,68,Princeton Village Assisted Living Residence,14370 SE Oregon Trail Drive,"Clackamas, OR 97015",,"ARHC PVCLAOR01 TRS, LLC","FM Princeton, LLC" -70M216,ALF,54,Macdonald Residence,605 NW Couch Street,"Portland, OR 97209",,Macdonald Residence Limited Partnership,"Mennonite Management Services, Inc." -70M217,ALF,95,Aspen Ridge Retirement Community,1010 NE Purcell,"Bend, OR 97701",,"FM Aspen Ret, LLC","Frontier Management, LLC" -70M218,ALF,85,Avamere at Waterford Assisted Living Facility,760 Spring Street,"Medford, OR 97504",,"Waterford Operations, LLC","Waterford Operations, LLC" -70M219,ALF,65,"Springs at Mill Creek, The",1201 W 10th Street,"The Dalles, OR 97058",,"HSRE-Springs II at the Dalles, LLP","The Springs Living, LLC" -70M220,ALF,49,Redwood Terrace,3111 Canal Ave,"Grants Pass, OR 97527",,"Oregon Heights, LLC","Concepts in Community Living, Inc." -70M221,ALF,46,Prairie House Assisted Living Community,51485 Morson Street,"La Pine, OR 97739",,"Assisted Living Alternatives, Inc.",Ridgeline Management Co. -70M222,ALF,62,Cedar Village Assisted Living Community,4452 Lancaster Dr. NE,"Salem, OR 97305",,"ARHC CVSALOR01 TRS, LLC","FM Cedar Village, LLC" -70M223,ALF,56,Settler's Park Assisted Living Community,2895 17th St.,"Baker City, OR 97814",,LSREF Golden Ops 26 (OR) LLC,"SLH Rainier Manager, LLC" -70M225,ALF,76,Oak Park Assisted Living Community,1400 NE Rocky Ridge Dr.,"Roseburg, OR 97470",,"Roseburg Assisted Living, LLC",Bonaventure Senior Living -70M226,ALF,62,Brookdale Springfield Woodside,4851 Main Street,"Springfield, OR 97478",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M227,ALF,65,Avamere at Sherwood Assisted Living Facility,16500 SW Century Dr.,"Sherwood, OR 97140",,"Avamere Sherwood Operations, LLC","Avamere-Sherwood Operations, LLC" -70M228,ALF,55,Cascadia Village Retirement Comm.,39495 Cascadia Village Drive,"Sandy, OR 97055",,"Sandy Assisted Living, LLC",Bonaventure Senior Living -70M229,ALF,86,Callahan Village,1801 Garden Valley Blvd.,"Roseburg, OR 97470",,LSREF Golden Ops UE (OR) LLC,"Frontier Management, LLC" -70M230,ALF,75,Pelican Pointe Assisted Living Community,615 Washburn Way,"Klamath Falls, OR 97603",,"ARHC PPKLAOR01 TRS, LLC","FM Pelican, LLC" -70M231,ALF,65,Avamere at Sandy Assisted Living Facility,17727 SE Langensand,"Sandy, OR 97055",,"Avamere-Sandy Operations, LLC","Avamere-Sandy Operations, LLC" -70M233,ALF,53,Morrow Heights Retirement & Assisted Living Community,176 Wards Creek Road,"Rogue River, OR 97537",,LSREF Golden Ops 14 (OR) LLC,"Frontier Management, LLC" -70M234,ALF,70,Brookdale Eagle Point,261 Loto Street,"Eagle Point, OR 97524",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M236,ALF,79,Brookdale Rose Valley Scappoose,33800 SE Frederick Street,"Scappoose, OR 97056",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M237,ALF,36,Nyssa Gardens Assisted Living Facility,1101 Park Avenue,"Nyssa, OR 97913",,Malheur Memorial Hospital District,Malheur Memorial Health District -70M238,ALF,60,McKay Creek Estates,1601 Southgate Place,"Pendleton, OR 97801",,"Pendleton Ventures, L.L.C.","Prestige Senior Living, L.L.C." -70M239,ALF,80,Courtyard at Mt. Tabor,6323 SE Division,"Portland, OR 97206",,"Courtyard Assisted Members, LLC","Integral Senior Living, LLC" -70M240,ALF,75,Prestige Senior Living Huntington Terrace,1410 NE Cleveland,"Gresham, OR 97030",,CHP-Gresham-Huntington Terrace OR Tenant Corp.,"Prestige Senior Living, L.L.C" -70M241,ALF,53,High Lookee Lodge,2321 Ollallie Lane PO Box 6,"Warm Springs, OR 97761",,Confederated Tribes of Warm Springs Reservation of Oregon,Confederated Tribes of Warm Springs Reservation of Oregon -70M242,ALF,85,Lone Oak Assisted Living Facility,2615 Lone Oak Way,"Eugene, OR 97402",,LSREF Golden Ops 14 (OR) LLC,"Frontier Management, LLC" -70M243,ALF,75,Prestige Senior Living Beaverton Hills,4525 SW 99th Avenue,"Beaverton, OR 97005",,CHP Beaverton OR Tenant Corp,"Prestige Senior Living, LLC" -70M245,ALF,75,Avamere at Hillsboro Assisted Living Facility,2000 SE 30th Ave.,"Hillsboro, OR 97123",,"Avamere Hillsboro Operations, LLC","Avamere-Hillsboro Operations, LLC" -70M247,ALF,60,Cambridge Terrace Assisted Living,2800 14th Ave. SE,"Albany, OR 97321",,Albany Assisted Living LLC,Mountain West Retirement Corp. -70M248,ALF,97,Sun Terrace Hermiston,1550 NW 11th St.,"Hermiston, OR 97838",,Clay Davis Stroud - Oregon LLC,"Regency Pacific Management, LLC" -70M250,ALF,68,Deer Meadow Assisted Living Community,1350 W Main St,"Sheridan, OR 97378",,Aspen Foundation III,Aspen Foundation III -70M251,ALF,75,Brookdale Stayton,2201 3rd Ave.,"Stayton, OR 97383",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." -70M252,ALF,38,Laurelhurst House,15 SE 55th Ave,"Portland, OR 97215",,"Laurelhurst House, LLC","Touchstone Communities, LLC" -70M253,ALF,51,Ridgeview Assisted Living Center,872 Golfview Drive,"Medford, OR 97504",,"Ridgeview Assisted Living Center, LLC","Ridgeview Assisted Living Center, LLC" -70M254,ALF,90,Brookdale Grants Pass Village,1420 Redwood Circle,"Grants Pass, OR 97527",,"S-H OpCO Spring Village, LLC","Brookdale Senior Living Communities, Inc." -70M255,ALF,55,Woodland Heights,9355 SW McDonald St.,"Tigard, OR 97224",,"Woodland Heights, LLC","Woodland Heights, LLC" -70M256,ALF,55,Wildflower Lodge Assisted Living Community,508 16th St.,"LaGrande, OR 97850",,LSREF Golden Ops 14 (OR) LLC,"SLH Rainier Manager, LLC" -70M257,ALF,79,Marie Rose Center Assisted Living,17360 Holy Names Drive,"Lake Oswego, OR 97034",,"Mary's Woods at Marylhurst, Inc.","Mary's Woods at Marylhurst, Inc." -70M258,ALF,70,Avamere Living at St. Helens,2400 Gable Rd.,"St. Helens, OR 97051",,"Avamere - St. Helens Operations, LLC","Avamere-St.Helens Operations, LLC" -70M313,ALF,84,"Springs at Tanasbourne II, LLC",1950 NW 192nd Avenue,"Hillsboro, OR 97124",,"Springs at Tanasbourne II, LLC","The Springs Living, LLC" -70M350,ALF,119,"Village at Keizer Ridge, The",1165 McGee Court,"Keizer, OR 97303",,"VKR, LLC","Keizer Care Properties, LLC" -7MU215,ALF,126,St. Anthony Village,3560 SE 79th Avenue,"Portland, OR 97206",,St. Anthony Village Associates LP,SAGE -0O0O0O,,57,Fake Facility,1234 Fake St,"Nowheresville, NY 05400",,Fake Company,"Not a Company, LLC" \ No newline at end of file +facid,fac_type,capacity,fac_name,fac_address,city_state_zip,,owner,operator +385008,NF,96,Presbyterian Community Care Center,1085 N Oregon St,"Ontario, OR 97914",,"Presbyterian Nursing Home, Inc.","Presbyterian Nursing Home, Inc." +385010,NF,159,Laurelhurst Village Rehabilitation Center,3060 SE Stark St,"Portland, OR 97214",,"Laurelhurst Operations, LLC","Laurelhurst Operations, LLC" +385015,NF,128,Regency Gresham Nursing & Rehabilitation Center,5905 SE Powell Valley Rd,"Gresham, OR 97080",,"Regency Gresham Nursing & Rehabilitation Center, LLC","Regency Pacific Management, LLC" +385018,NF,98,Providence Benedictine Nursing Center,540 South Main St,"Mt. Angel, OR 97362",,Providence Health & Services - Oregon,Providence Health & Services - Oregon +385024,NF,91,Avamere Health Services of Rogue Valley,625 Stevens St,"Medford, OR 97504",,"Medford Operations, LLC","Medford Operations, LLC" +385031,NF,127,Avamere Crestview of Portland,6530 SW 30th Avenue,"Portland, OR 97239",,"Crestview Operations, LLC","Crestview Operations, LLC" +385039,NF,84,Baycrest Health Center,3959 Sheridan Ave,"North Bend, OR 97459",,"Bay Area Properties, LLC","Radiant Senior Living, Inc." +385044,NF,83,Prestige Care and Rehabilitation of Menlo Park,745 NE 122nd Ave,"Portland, OR 97230",,Care Center (Menlo Park) Inc.,"Prestige Care, Inc." +385045,NF,99,Porthaven Healthcare Center,5330 NE Prescott,"Portland, OR 97218",,Care Center (Porthaven) Inc.,"Prestige Care, Inc." +385046,NF,83,Hillside Heights Rehabilitation Center,1201 McLean Blvd,"Eugene, OR 97405",,Hillside Heights L.L.C.,"Pinnacle Healthcare Management, Inc." +385049,NF,90,Columbia Basin Care Facility,1015 Webber Rd,"The Dalles, OR 97058",,"Wasco County Nursing Care, Inc.","Aidan Health Services, Inc." +385053,NF,92,Avamere Rehabilitation of Eugene,2360 Chambers St,"Eugene, OR 97405",,"Eugene Rehabilitation, LLC.","Eugene Rehabilitation, LLC." +385055,NF,64,Prestige Care and Rehabilitation of Reedwood,3540 SE Francis St,"Portland, OR 97202",,Care Center (Reedwood) Inc.,Prestige Care Inc. +385064,NF,102,Regency Care of Rogue Valley,1710 NE Fairview Ave,"Grants Pass, OR 97526",,"BD Grants Pass I, LLC","Regency Pacific Management, LLC" +385068,NF,106,Village Health Care,3955 SE 182nd Ave,"Gresham, OR 97030",,"Village Health Care I, LLC","Village Health Care I, LLC" +385072,NF,135,Corvallis Manor Nursing & Rehabilitation Center,160 NE Conifer Blvd,"Corvallis, OR 97330",,"MCH Enterprises, Inc.","Pinnacle Healthcare Management, Inc." +385077,NF,136,Marquis Springfield,1333 N First,"Springfield, OR 97477",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385091,NF,87,Hearthstone Nursing and Rehabilitation Center,2901 E Barnett Rd,"Medford, OR 97504",,"Hearthstone Operator, LLC","Pinnacle Healthcare Management, Inc." +385104,NF,100,Hood River Care Center,729 Henderson Rd,"Hood River, OR 97031",,"Care Center (Hood River) Inc.,","Prestige Care, Inc." +385107,NF,67,Timberview Care Center,1023 6th Avenue Southwest,"Albany, OR 97321",,"PCI Care Venture I, Inc.","Prestige Care, Inc." +385112,NF,180,West Hills Health & Rehabilitation Center,5701 SW Multnomah Blvd,"Portland, OR 97219",,West Hills Convalescent Center Limited Partnership,West Hills Convalescent Center Limited Partnership +385115,NF,47,Lakeview Gardens LLC,700 South J,"Lakeview, OR 97630",,"Lakeview Gardens, LLC","Lakeview Gardens, LLC" +385117,NF,80,French Prairie Nursing and Rehabilitation Center,601 Evergreen Rd,"Woodburn, OR 97071",,"3C2MD, Inc.","Pinnacle Healthcare Management, Inc." +385120,NF,121,Valley West Health Care Center,2300 Warren St,"Eugene, OR 97405",,"Life Care Centers Of America, Inc.","Life Care Centers Of America, Inc." +385121,NF,100,Friendship Health Center,3320 SE Holgate Blvd,"Portland, OR 97202",,"Friendship Health Center, Inc.","Friendship Health Center, Inc." +385125,NF,95,Avamere Rehabilitation of Oregon City,1400 Division St,"Oregon City, OR 97045",,"Mountain View Rehab, LLC","Mountain View Rehab, LLC" +385126,NF,117,Avamere at Three Fountains,835 Crater Lake Ave,"Medford, OR 97504",,"Waterford Operations, LLC","Waterford Operations, LLC" +385132,NF,148,Avamere Rehabilitation of King City,16485 SW Pacific Hwy,"Tigard, OR 97224",,"King City Rehab, LLC","King City Rehab, LLC" +385133,NF,82,Good Samaritan Society - Fairlawn Village,3457 NE Division,"Gresham, OR 97030",,Evangelical Lutheran Good Sam. Society,Evangelical Lutheran Good Sam. Society +385136,NF,100,Glisan Care Center,9750 NE Glisan St,"Portland, OR 97220",,Care Center (Glisan) Inc.,"Prestige Care, Inc." +385137,NF,95,Marquis Plum Ridge,1401 Bryant Williams Dr,"Klamath Falls, OR 97601",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385138,NF,74,Pilot Butte Rehabilitation Center,1876 NE Hwy 20,"Bend, OR 97701",,"BD Bend II, LLC","Regency Pacific Management, LLC" +385141,NF,120,Marquis Mt Tabor,6040 SE Belmont,"Portland, OR 97215",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385142,NF,72,Regency Florence,1951 E 21St Street,"Florence, OR 97439",,"Regency Florence, LLC","Regency Pacific Management, LLC" +385143,NF,118,Umpqua Valley Nursing & Rehabilitation Center,525 W Umpqua St,"Roseburg, OR 97470",,"Umpqua Valley Nursing & Rehabilitation Center, LLC","Pinnacle Healthcare Management, Inc." +385144,NF,71,Clatsop Care Center,646 16th St,"Astoria, OR 97103",,Clatsop Care Center Health District,Clatsop Care Center Health District +385145,NF,88,Robison Jewish Health Center,6125 SW Boundary,"Portland, OR 97221",,Robison Jewish Home,Robison Jewish Home +385147,NF,87,Good Samaritan Society - Eugene Village,3500 Hilyard St,"Eugene, OR 97405",,The Evangelical Lutheran Good Samaritan,The Evangelical Lutheran Good Samaritan +385148,NF,145,Royale Gardens Health & Rehabilitation Center,2075 NW Highland Ave,"Grants Pass, OR 97526",,"RGO, LLC","Pinnacle Healthcare Management, Inc." +385149,NF,119,Highland House Nursing & Rehabilitation Center,2201 NW Highland Ave,"Grants Pass, OR 97526",,Highland House Inc.,"Pinnacle Healthcare Management, Inc." +385150,NF,92,Molalla Manor Care Center,301 Ridings Ave,"Molalla, OR 97038",,Care Center (Molalla) Inc.,"Prestige Care, Inc." +385151,NF,121,Rose Haven Nursing Center,740 NW Hill Place,"Roseburg, OR 97471",,"Fisher Care, Inc.","Pinnacle Healthcare Management, Inc." +385152,NF,80,Coast Fork Nursing Center,515 Grant St.,"Cottage Grove, OR 97424",,"Coast Fork Nursing Center, Inc.","Prestige Care, Inc." +385155,NF,114,Forest Grove Rehabilitation and Care Center,3900 Pacific Ave,"Forest Grove, OR 97116",,"PCI Care Venture I, Inc.","Prestige Care, Inc." +385156,NF,110,Green Valley Rehabilitation Health Center,1735 Adkins St,"Eugene, OR 97401",,Green Valley L.L.C.,"Pinnacle Healthcare Management, Inc." +385157,NF,114,Life Care Center Of Coos Bay,2890 Ocean Boulevard,"Coos Bay, OR 97420",,"Life Care Centers Of America, Inc.","Life Care Centers Of America, Inc." +385161,NF,129,Milton Freewater Health and Rehabilitation Center,120 Elzora St,"Milton-Freewater, OR 97862",,"Evergreen Oregon Healthcare Orchards Rehabilitation, L.L.C.","EmpRes Healthcare Management, LLC" +385162,NF,52,Avamere Rehabilitation of Newport,835 SW 11th,"Newport, OR 97365",,"Newport Rehabilitation, LLC.","Newport Rehabilitation, LLC." +385164,NF,29,Aidan Senior Living at Reedsport,600 Ranch Rd,"Reedsport, OR 97467",,"Aidan Senior Living at Reedsport, Inc","Aidan Senior Living at Reedsport, Inc" +385165,NF,59,Good Samaritan Society - Curry Village,1 Park Avenue,"Brookings, OR 97415",,The Evangelical Lutheran Good Samaritan,The Evangelical Lutheran Good Samaritan +385166,NF,165,Maryville Nursing Home,14645 SW Farmington Rd,"Beaverton, OR 97007",,Sisters of St. Mary of Oregon Maryville Corp.,Sisters of St. Mary of Oregon Maryville Corp. +385167,NF,110,South Hills Rehabilitation Center,1166 East 28th Ave,"Eugene, OR 97403",,"Garber Enterprises, Inc.","Pinnacle Healthcare Management, Inc." +385168,NF,84,Avamere Rehabilitation of Lebanon,350 S 8th St,"Lebanon, OR 97355",,"Lebanon Care Center, LLC","Lebanon Care Center, LLC" +385171,NF,110,Life Care Center Of McMinnville,1309 NE 27th St,"McMinnville, OR 97128",,"McMinnville Medical Investors , LLC ","Life Care Centers Of America, Inc." +385172,NF,83,The Dalles Health and Rehabilitation Center,1023 W 25th,"The Dalles, OR 97058",,"Evergreen Oregon Healthcare Valley Vista, L.L.C.","EmpRes Healthcare Management, LLC" +385180,NF,54,Marquis Newberg,441 Werth Blvd.,"Newberg, OR 97132",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385181,NF,20,"East Cascade Retirement Community, LLC",175 NE 16th St.,"Madras, OR 97741",,"East Cascade Retirement Community, LLC","Senior Housing Managers, LLC" +385182,NF,76,Creswell Health and Rehabilitation Center,735 South 2nd St,"Creswell, OR 97426",,Care Center (Laneco) Inc.,Prestige Care Inc. +385183,NF,80,Marquis Centennial Post Acute Rehab,725 SE 202nd Ave,"Portland, OR 97233",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +385185,NF,119,Avamere Riverpark of Eugene,425 Alexander Loop,"Eugene, OR 97401",,"Riverpark Operations, LLC","Riverpark Operations, LLC" +385187,NF,105,Cascade Terrace Nursing Center,5601 SE 122nd,"Portland, OR 97236",,Care Center (Cascade Terrace) Inc.,"Prestige Care, Inc." +385188,NF,80,Independence Health and Rehabilitation Center,1525 Monmouth St,"Independence, OR 97351",,Evergreen Oregon Healthcare Independence L.L.C.,"EmpRes Healthcare Management, LLC" +385189,NF,88,Avamere Transitional Care at Sunnyside,4515 Sunnyside Rd SE,"Salem, OR 97302",,"Sunnyside Operations, LLC","Sunnyside Operations, LLC" +385190,NF,78,Prestige Post-Acute and Rehabilitation Center-Gresham,405 NE 5th St,"Gresham, OR 97030",,Pacific Regency Care LLC,Prestige Care Inc. +385195,NF,104,Avamere Rehabilitation of Beaverton,11850 SW Allen Blvd,"Beaverton, OR 97005",,"Beaverton Rehab & Specialty Care, LLC","Beaverton Rehab & Specialty Care, LLC" +385197,NF,87,Linda Vista Nursing & Rehab Center,135 Maple St,"Ashland, OR 97520",,Care Center (Linda Vista) Inc.,"Prestige Care, Inc." +385199,NF,84,Chehalem Health & Rehab Center,1900 E Fulton St,"Newberg, OR 97132",,Care Center (Chehalem) Inc.,"Prestige Care, Inc." +385200,NF,6,Willamette View Health Center,13145 SE River Rd,"Milwaukie, OR 97222",,"Willamette View, Inc. dba","Willamette View, Inc." +385201,NF,59,Willowbrook Terrace,707 SW 37th Street,"Pendleton, OR 97801",,"Care Center (Willowbrook), Inc.","Prestige Care, Inc." +385203,NF,87,Avamere Rehabilitation of Clackamas,220 East Hereford,"Gladstone, OR 97027",,"Clackamas Rehabilitation , LLC.","Clackamas Rehabilitation, LLC." +385204,NF,63,Marquis Forest Grove Post Acute Rehab,3300 19th Avenue,"Forest Grove, OR 97116",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +385206,NF,95,Mennonite Home,5353 Columbus Street Southeast,"Albany, OR 97322",,"Mennonite Home Of Albany, Inc.","Mennonite Home Of Albany, Inc." +385207,NF,121,Dallas Retirement Village Health Center,377 NW Jasper Street,"Dallas, OR 97338",,"Dallas Health Care Center, LLC",Life Care Services LLC +385208,NF,70,Marquis Piedmont Post Acute Rehab,319 NE Russet,"Portland, OR 97211",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +385211,NF,76,LaGrande Post Acute Rehab,91 Aries Lane,"La Grande, OR 97850",,"Evergreen Oregon Healthcare Mt Vista, L.L.C.","EmpRes Healthcare Management, LLC" +385214,NF,54,Marquis Mill Park,1475 SE 100th Avenue,"Portland, OR 97216",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385217,NF,78,EmpRes Hillsboro Health and Rehabilitation Center,1778 NE Cornell Rd,"Hillsboro, OR 97124",,"Evergreen Oregon Healthcare Tualatin, L.L.C.","EmpRes Healthcare Management, LLC" +385218,NF,73,Marquis Vermont Hills,6010 SW Shattuck Rd,"Portland, OR 97221",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385219,NF,93,Care Center East Health & Specialty Care Center,11325 NE Weidler,"Portland, OR 97220",,FMG Northeast Weidler Street Oregon LLC,FMG Northeast Weidler Street Oregon LLC +385220,NF,74,Regency Albany,805 19th St. SE,"Albany, OR 97322",,"Regency Albany, LLC","Regency Pacific Management, LLC" +385221,NF,102,Marquis Oregon City Post Acute Rehab,1680 Molalla Avenue,"Oregon City, OR 97045",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +385222,NF,92,Meadow Park Health & Specialty Care Center,75 Shore Drive,"St Helens, OR 97051",,"FMG Shore Drive Oregon, LLC","FMG Shore Drive Oregon, LLC" +385224,NF,100,Windsor Health and Rehabilitation Center,820 Cottage St NE,"Salem, OR 97301",,Evergreen Oregon Healthcare Salem L.L.C.,"EmpRes Healthcare Management, LLC" +385225,NF,96,Prestige Post-Acute and Rehabilitation Center - McMinnville,421 S Evans St,"McMinnville, OR 97128",,Care Center (McMinnville) Inc.,"Prestige Care, Inc." +385228,NF,105,Portland Health and Rehabilitation Center,12441 SE Stark St,"Portland, OR 97233",,"Evergreen Oregon Healthcare Portland, L.L.C.","EmpRes Healthcare Management, LLC" +385229,NF,53,Avamere Rehabilitation of Junction City,530 Birch St,"Junction City, OR 97448",,"Junction City Rehabilitation, LLC.","Junction City Rehabilitation, LLC." +385230,NF,50,Regency Redmond Rehabilitation and Nursing Center,3025 SW Reservoir,"Redmond, OR 97756",,"BD Redmond IV, LLC","Regency Pacific Management, LLC" +385232,NF,44,Laurel Hill Nursing Center,859 NE Sixth St,"Grants Pass, OR 97526",,"BD Grants Pass II, LLC","Regency Pacific Management, LLC" +385233,NF,69,Avamere Court at Keizer,5210 River Rd N,"Keizer, OR 97303",,"Keizer Campus Operations, LLC","Keizer Campus Operations, LLC" +385234,NF,80,Salem Transitional Care,3445 Boone Road SE,"Salem, OR 97317",,"South Salem Rehabilitation, LLC.","South Salem Rehabilitation, LLC." +385236,NF,51,Town Center Village Rehab,8607 SE Causey Ave,"Portland, OR 97086",,"TVC Employees, LLC","Generations, LLC" +385237,NF,63,Fernhill Estates,5737 NE 37th,"Portland, OR 97211",,"Fernhill Estates, LLC","Dakavia Management, Corp." +385239,NF,92,Avamere Rehabilitation of Coos Bay,2625 Koos Bay Blvd,"Coos Bay, OR 97420",,"Coos Bay Rehabilitation, LLC.","Coos Bay Rehabilitation, LLC." +385240,NF,214,Marian Estates,390 Church St,"Sublimity, OR 97385",,"Ernmaur, Inc.",Marian Estates Support Services +385241,NF,49,Sherwood Park Nursing & Rehab Center,4062 Arleta Ave NE,"Keizer, OR 97303",,"Sherwood Park Nursing Home, Inc.","Sherwood Park Nursing Home, Inc." +385242,NF,41,Avamere Twin Oaks of Sweet Home,950 Nandina Street,"Sweet Home, OR 97386",,"Twin Oaks Rehab, LLC.","Twin Oaks Rehab, LLC." +385244,NF,50,Nehalem Valley Care Center,"PO Box 6, 280 Rowe St","Wheeler, OR 97147",,"Wheeler Care Center, LLC","Aidan Health Services, Inc." +385245,NF,53,Oregon City Health Care Center,148 Hood St,"Oregon City, OR 97045",,Care Center (Oregon City) Inc.,"Prestige Care, Inc." +385250,NF,68,Rogue Valley Manor Health Center,1200 Mira Mar Ave,"Medford, OR 97504",,Rogue Valley Manor,"Pacific Retirement Services, Inc." +385251,NF,87,Avamere Rehabilitation of Hillsboro,650 SE Oak St,"Hillsboro, OR 97123",,"Peckham-Miller, Inc. dba","Peckham-Miller, Inc." +385253,NF,49,Bend Transitional Care,900 NE 27th Street,"Bend, OR 97701",,"Ohana Harmony House, LLC","Ohana Harmony House, LLC" +385254,NF,35,Myrtle Point Care Center, 637 Ash St,"Myrtle Point, OR 97458",,"Care Centers Management, Inc.","Dakavia Management, Corp." +385257,NF,151,Oregon Veterans' Home,700 Veterans Drive,"The Dalles, OR 97058",,Oregon Dept Of Veterans Affairs,Veterans Care Centers of Oregon +385258,NF,55,Park Forest Care Center,8643 NE Beech St,"Portland, OR 97220",,Care Center ( Park Forest) Inc.,"Prestige Care, Inc." +385259,NF,51,Holladay Park Plaza,1300 NE 16th Ave,"Portland, OR 97232",,"Holladay Park Plaza, Inc.","Pacific Retirement Services, Inc." +385260,NF,50,Marquis Hope Village,1577 S Ivy,"Canby, OR 97013",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385261,NF,44,Regency Prineville Rehabilitation and Nursing Center,950 NE Elm Street,"Prineville, OR 97754",,"BD Prineville II, LLC","Regency Pacific Management, LLC" +385262,NF,52,Marquis Silver Garden,115 S James St,"Silverton, OR 97381",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +385263,NF,105,Regency Hermiston Nursing & Rehabilitation Center,970 W Juniper Ave,"Hermiston, OR 97838",,"Regency Hermiston Nursing & Rehabilitation Center, LLC","Regency Pacific Management, LLC" +385264,NF,53,"Trinity Mission Health & Rehab of Portland, LLC",10435 SE Cora,"Portland, OR 97266",,"Trinity Mission Health & Rehab of Portland, LLC","Trinity Mission Health & Rehab of Portland, LLC" +385265,NF,5,Mary's Woods at Marylhurst,17360 Holy Names Drive,"Lake Oswego, OR 97034",,"Mary's Woods at Marylhurst, Inc.","Mary's Woods at Marylhurst, Inc." +385266,NF,50,Marquis Wilsonville Post Acute Rehab,30900 SW Parkway Avenue,"Wilsonville, OR 97070",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +385268,NF,59,Gateway Care & Retirement Center,39 NE 102nd,"Portland, OR 97220",,"Sapphire at Gateway, LCC","Sapphire at Gateway, LLC" +385270,NF,96,Prestige Post-Acute and Rehabilitation Center - Milwaukie,12045 SE Stanley Ave.,"Milwaukie, OR 97222",,"Care Center (Milwaukie), Inc.","Prestige Care, Inc." +385271,NF,45,"Pearl at Kruse Way, The",4550 Carman Drive,"Lake Oswego, OR 97035",,"Avamere Lake Oswego Operations Investors, LLC","Avamere Lake Oswego Operations Investors, LLC" +385272,NF,112,Pacific Health and Rehabilitation,14145 SW 105th Ave.,"Tigard, OR 97224",,"Pacific Gardens Estates, LLC","Dakavia Management, Corp." +385273,NF,33,Pioneer Nursing Home,1060 D Street W,"Vale, OR 97918",,Pioneer Nursing Home Health District,Pioneer Nursing Home Health District +385275,NF,51,Sheridan Care Center,411 SE Sheridan Road,"Sheridan, OR 97378",,"Sheridan Care Center, LLC ","Dakavia Management, Corp." +38A001,NF,58,Providence Child Center,830 NE 47th Ave,"Portland, OR 97213",,Providence Health & Services - Oregon,Providence Health & Services - Oregon +38A026,NF,39,Marquis Autumn Hills Memory Care,6630 SW Beav-Hillsdale Hwy,"Portland, OR 97225",,"Marquis Companies II, Inc.","Marquis Companies II, Inc." +380E19,NF,71,Rose Linn Care Center,2330 Debok,"West Linn, OR 97068",,"West Linn Care Center Operating Company, LLC","Benicia Senior Living, LLC" +380E25,NF,40,Columbia Care Center,33910 E Columbia Ave PO Box 1068,"Scappoose, OR 97056",,EEA Company,EEA Company +380E33,NF,46,Regency Care of Central Oregon,119 SE Wilson Ave,"Bend, OR 97702",,"BD Bend III, LLC","Regency Pacific Management, LLC" +380E41,NF,40,Blue Mountain Care Center,112 E Fifth St-PO Box 305,"Prairie City, OR 97869",,Blue Mountain Hospital District,Blue Mountain Hospital District +380E76,NF,76,Tierra Rose Care Center,4254 Weathers St NE,"Salem, OR 97301",,"CML, Inc.","CML, Inc." +380E127,NF,114,Healthcare at Foster Creek,6003 SE 136th,"Portland, OR 97236",,"St. Jude Operating Company, LLC","Benicia Senior Living, LLC" +380E158,NF,30,Rose City Nursing Home,34 NE 20th,"Portland, OR 97232",,"Geistlinger Enterprises, Inc.","Geistlinger Enterprises, Inc." +380E174,NF,40,Cornerstone Care Option,12640 SE Bush,"Portland, OR 97236",,"Cornerstone Care Option, Inc","Cornerstone Care Option, Inc." +380E175,NF,60,Village Manor,2060 NE 238th Drive,"Wood Village, OR 97060",,"V.M.C., Inc.","V.M.C., Inc." +380E189,NF,80,Gracelen Terrace Long Term Care Facility,10948 SE Boise St,"Portland, OR 97266",,"H & L Care Centers, Inc.","H & L Care Centers, Inc." +380E197,NF,41,Lawrence Convalescent Center,812 SE 48th Ave,"Portland, OR 97215",,Charles Lawrence,Charles Lawrence +38L300,NF,54,Marquis Tualatin Post Acute Rehab,19945 SW Boones Ferry,"Tualatin, Oregon, OR 97062",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +38L400,NF,44,Mirabella Portland,3550 SW Bond Ave.,"Portland, OR 97239",,Mirabella at South Waterfront,"Pacific Retirement Services, Inc." +38L501,NF,20,Village at Hillside,440 NW Hillside Parkway,"McMinnville, OR 97128",,"EmeriCare, Inc","EmeriCare, Inc." +38L503,NF,154,Lebanon Veterans Home,600 North 5th Street,"Lebanon, OR 97355",,Oregon Dept Of Veterans Affairs,Veterans Care Centers of Oregon +38L544,NF,45,Rose Villa Senior Living,13505 SE River Rd,"Portland, OR 97222",,"Rose Villa, Inc.","Rose Villa, Inc." +38L756,NF,32,Cascade Manor,65 West 30th,"Eugene, OR 97405",,"Cascade Manor, Inc.","Pacific Retirement Services, Inc." +50A028,RCF,70,Farmington Square - Beaverton,14420 SW Farmington Rd,"Beaverton, OR 97005",,"RSL Beaverton, LLC","Radiant Senior Living, Inc." +50A235,RCF,20,Avamere at Waterford,760 Spring Street,"Medford, OR 97504",,"Waterford Operations, LLC","Waterford Operations, LLC" +50A236,RCF,60,Brookdale Troutdale,1201 SW Cherry Park Rd.,"Troutdale, OR 97060",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50A239,RCF,48,"Regent Court, a Blue Harbor Senior Living Community",400 NW Elks Drive,"Corvallis, OR 97330",,Regent Court Management LLC,Regent Court Management LLC +50A244,RCF,22,Marquis Autumn Hills Residential Memory Care,6630 SW Beaverton-Hillsdale Hwy.,"Portland, OR 97225",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +50A253,RCF,58,Bridgecreek Memory Care Community,1401 12th St,"Lebanon, OR 97355",,"Bridgecreek Investors, LLC","Ageia Health Services, LLC" +50A262,RCF,24,Providence Brookside Memory Care,1550 Brookside Dr.,"Hood River, OR 97031",,Providence Health & Services - Oregon,Providence Health System - Oregon +50A263,RCF,59,Brookdale Bend,1099 NE Watt Way,"Bend, OR 97701",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50M006,RCF,10,"Autumn Garden Home RCF, Inc.",6215 SE Hazel Ave.,"Portland, OR 97206",,"Autumn Garden Home RCF, LLC","Autumn Garden Home RCF, LLC" +50M012,RCF,32,Cascade Park Retirement Center,950 N Cascade Dr,"Woodburn, OR 97071",,"Woodburn Investment Associates, Ltd.","Century Park Associates, LLC" +50M019,RCF,59,Emerald Gardens,1890 N Newberg Hwy,"Woodburn, OR 97071",,"RSL Woodburn, LLC","Radiant Senior Living, Inc." +50M021,RCF,16,Comfort Care,1735 Kane St,"Klamath Falls, OR 97603",,Mary Nork,Mary Nork +50M025,RCF,15,Elderly Care Home,12435 SW 121st,"Tigard, OR 97223",,"Elderly Care Home, Inc.","Elderly Care Home, Inc." +50M026,RCF,34,Ellendale Residential Care Center,511 E Ellendale Ave,"Dallas, OR 97338",,"Dallas Care Center, Inc.","Dallas Care Center, Inc." +50M037,RCF,85,Firwood Gardens RCF,819 NE 122nd Ave,"Portland, OR 97230",,"Sapphire at Firwood, LLC","Sapphire at Firwood, LLC" +50M044,RCF,50,Golden Acres Retirement Center,12711 SE Holgate Blvd,"Portland, OR 97236",,Sandra Tidwell,Sandra Tidwell +50M048,RCF,13,Donham Place,5833 N Lombard St,"Portland, OR 97203",,"Donham Place, LLC","Donham Place, LLC" +50M049,RCF,62,Harmony Guest Home,351 SE Fifth St,"Hillsboro, OR 97123",,"Harmony Guest Home, Inc.","Harmony Guest Home, Inc." +50M054,RCF,120,Brookdale River Valley - Tualatin,19200 SW 65th Ave,"Tualatin, OR 97062",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +50M055,RCF,88,Brookdale Mt. Hood,25200 SE Stark St,"Gresham, OR 97030",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50M056,RCF,95,Brookdale Medford,3033 Barnett Rd,"Medford, OR 97504",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50M065,RCF,50,Jefferson Lodge Memory Care Community,664 SE Jefferson St,"Dallas, OR 97338",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +50M081,RCF,23,Milwaukie Care Center,14107 SE Redwood Ave,"Milwaukie, OR 97222",,"Milwaukie Care Center, Inc.","Milwaukie Care Center, Inc." +50M086,RCF,46,Mt. Scott Residential Care Home,8014 SE Lambert St,"Portland, OR 97206",,"Sistere, Inc.","Sistere, Inc." +50M088,RCF,20,Myrtle Point Care Center RCF,637 Ash St,"Myrtle Point, OR 97458",,"Care Centers Management, Inc.","Dakavia Management, Corp." +50M092,RCF,32,O'Hara's Manor,1250 SE Roberts,"Gresham, OR 97080",,"O'Hara's Manor, Inc.","O'Hara's Manor, Inc." +50M094,RCF,50,Oregon City Residential Care,515 10th St,"Oregon City, OR 97045",,"Valley View Care Centers, Inc.","Valley View Care Centers, Inc." +50M096,RCF,14,Our House Of Portland,2727 SE Alder,"Portland, OR 97214",,"Our House Of Portland, Inc","Our House of Portland, Inc." +50M098,RCF,,Aaren Brooke Place,995 N Oregon St,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50M098,RCF,14,Aaren Brooke Place,995 N Oregon St,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50M109,RCF,30,Tabor Crest Residential Care,7430 SE Division St,"Portland, OR 97206",,"Tabor Crest Residential Care, LLC","Tabor Crest Residential Care, LLC" +50M110,RCF,80,"Taft Home, The",1337 SW Washington St,"Portland, OR 97205",,"Concepts in Community Living, Inc.","Concepts in Community Living, Inc." +50M124,RCF,30,Harmony Estates Residential Care Center,87326 McTimmons Lane,"Bandon, OR 97411",,"Harmony Estates, Inc.","Harmony Estates, Inc." +50M132,RCF,60,River Grove Memory Care,140 Green Lane,"Eugene, OR 97404",,River Grove Operating Company,"Benecia Senior Living, LLC" +50M133,RCF,74,Oak Lane Retirement,727 SW Rogue River Ave,"Grants Pass, OR 97526",,"TSL Oak Lane, LLC","Tierra Senior Living, LLC" +50M138,RCF,36,Baycrest Assisted Care,3959 Sheridan Ave,"North Bend, OR 97459",,"Bay Area Properties, LLC","Radiant Senior Living, Inc." +50M142,RCF,82,Brookdale Ontario,1372 SW 8th Ave,"Ontario, OR 97914",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +50M144,RCF,50,Elizabethan Manor,44882 Mission Road,"Pendleton, OR 97801",,"Prestige Residential Community, L.L.C","Prestige Senior Living, L.L.C" +50M154,RCF,15,Forest Meadows RCF,625 Barbara Dr,"Grants Pass, OR 97526",,"Forest Meadows RCF, Inc.","Forest Meadows RCF, Inc." +50M157,RCF,29,Terwilliger Plaza - Metcalf Unit,2545 SW Terwilliger Blvd,"Portland, OR 97201",,"Terwilliger Plaza, Inc.","Terwilliger Plaza, Inc." +50M172,RCF,28,Chateau Gardens Memory Care Community,2669 S Cloverleaf Loop,"Springfield, OR 97477",,"Cloverleaf Assisted Living, LLC",Ridgeline Management Co. +50M174,RCF,85,"Woods at Willowcreek, The",4398 Glencoe St NE,"Salem, OR 97301",,"Lancaster Woods Operator, LLC","The Springs Living, LLC" +50M201,RCF,19,Haven House Retirement Center,714 Main Street PO Bos 386,"Fossil, OR 97830",,"Fossil Elderly Housing Committee, Inc.","Fossil Elderly Housing Committee, Inc." +50M204,RCF,9,Ashley Manor - Lund Lane,1040 Lund Lane,"Baker City, OR 97814",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50M208,RCF,37,Chetco Inn Residential Care Facility,417 Fern St,"Brookings, OR 97415",,Chetco Inn RCF Incorporated,Chetco Inn RCF Incorporated +50M209,RCF,36,Forest Glen Senior Residence,200 SW Frontage Rd.,"Canyonville, OR 97417",,Aspen Foundation,Aspen Foundation +50M211,RCF,28,Hill House,1325 SW Gibbs Street,"Portland, OR 97239",,"Peaks and Valleys, LLC","Peaks and Valleys, LLC" +50M218,RCF,42,Meadows Courtyard,13637 Garden Meadow Drive,"Oregon City, OR 97045",,"Meadows Courtyard, Inc.","Meadows Courtyard, Inc." +50M220,RCF,15,Ashley Manor - Shasta,475 S Shasta Pl. Longview Div.,"Burns, OR 97720",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50M225,RCF,16,Blue Haven RCF - Independence,202 South 9th Street,"Independence, OR 97351",,"Blue Haven Residential Care Facilities, Inc.","Blue Haven Residential Care Facilities, Inc." +50M227,RCF,16,Blue Haven RCF - Dallas,280 SE Uglow St,"Dallas, OR 97338",,"Blue Haven Residential Care Facilities, Inc.","Blue Haven Residential Care Facilities, Inc." +50M228,RCF,32,Brookdale Wilsonville,8170 Vlahos Drive,"Wilsonville, OR 97070",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +50M247,RCF,11,Pleasant Valley RCF,18857 SE Giese Rd.,"Gresham, OR 97080",,"BME Enterprises, Inc.","BME Enterprises, Inc." +50M264,RCF,16,Sherwood Pines Residential Care,87986 Sherwood,"Veneta, OR 97487",,"Sherwood Pines Residential Care, Inc.","Sherwood Pines Residential Care, Inc." +50M265,RCF,15,Ashley Manor - Rimrock,1600 SW Rimrock Way,"Redmond, OR 97756",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50M267,RCF,15,Ashley Manor - Pacific Heights,1995 8th St.,"Hood River, OR 97031",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50M268,RCF,32,Four Seasons RCF - Fairgrounds,2850 Evergreen Ave NE,"Salem, OR 97303",,Four Seasons RCF Fairgrounds,Four Seasons RCF Fairgrounds +50M300,RCF,44,Quail Park Memory Care Residences of Klamath Falls,320 Jade Terrace,"Klamath Falls, OR 97601",,"Quail Park of Klamath Falls Phase II, LLC",Living Care Lifestyles +50M422,RCF,16,Juniper House Memory Care,301 SW 28th Drive,"Pendleton, OR 97801",,Assisted Living Facilities Inc.,"Concepts in Community Living, Inc." +50M423,RCF,45,Marjorie House Memory Care Community,2855 NE Cumulus Avenue,"McMinnville, OR 97128",,"Marjorie House McMinnville, LLC","Marjorie House McMinnville, LLC" +50M424,RCF,30,Kinsington at Redwood Park,1390 Dowell Road,"Grants Pass, OR 97527",,"Heirloom Living Centers, LLC","Cameo Care Management, LLC" +50M425,RCF,28,Maple Valley Dementia Care,219 NE Fircrest Drive,"McMinnville, OR 97128",,"Maple Valley Dementia Care, Inc.","Maple Valley Dementia Care, Inc." +50M426,RCF,35,Countryside Living of Redmond,1350 NW Canal Blvd,"Redmond, OR 97756",,"Countryside Living of Redmond, LLC","Countryside Living of Redmond, LLC" +50M427,RCF,23,"Village at Keizer Ridge Memory Care, The",1165 McGee Court,"Keizer, OR 97303",,"VKR, LLC","Keizer Care Properties, LLC" +50R009,RCF,74,Pacifica Senior Living Calaroga Terrace,1400 NE Second Ave,"Portland, OR 97232",,"Pacifica Senior Living, LLC","Pacifica Senior Living, LLC" +50R014,RCF,49,Cherry Blossom Cottage,11177 SE Cherry Blossom Dr,"Portland, OR 97216",,"Sylvia's Legacy, Inc.","Sylvia's Legacy, Inc." +50R023,RCF,51,Conifer House Residential Care & Memory Care,145 NE Conifer Blvd,"Corvallis, OR 97330",,"Conifer House Operating Company, LLC","Benicia Senior Living, LLC" +50R038,RCF,19,Fountain Plaza,1441 Morrow Rd,"Medford, OR 97504",,"Fountain Plaza, L.L.C.","Dharma Healthcare Management, Inc." +50R040,RCF,155,Friendsview Retirement Community,1301 E Fulton St,"Newberg, OR 97132",,"Friendsview Manor, Inc.","Friendsview Manor, Inc." +50R046,RCF,54,Fox Hollow Residential Care Community,5320 Fox Hollow Rd,"Eugene, OR 97405",,"Regency At Fox Hollow, Inc.",Prestige Care Inc. +50R062,RCF,7,Hubbard Residential Care Facility,647 Junction Rd,"Glendale, OR 97442",,Norma Ann Hubbard,Norma Ann Hubbard +50R068,RCF,63,Avamere Court at Keizer RCF,5210 River Road N,"Keizer, OR 97307",,"Keizer Campus Operations, LLC","Keizer Campus Operations, LLC" +50R078,RCF,35,Brookdale McMinnville Town Center,775 East 27th,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50R085,RCF,29,Mt. Angel Towers,One Towers Lane Box 2120,"Mt. Angel, OR 97362",,"Mt. Angel Towers, Oregon, Ltd.","Mt. Angel Towers, Oregon, Ltd." +50R091,RCF,115,Odd Fellows Home Of Oregon,3102 SE Holgate Blvd,"Portland, OR 97202",,Odd Fellows Home of Oregon,Odd Fellows Home of Oregon +50R108,RCF,39,Sweetbriar Villa,6135 E St.,"Springfield, OR 97478",,"RSL Springfield, LLC","Radiant Senior Living, Inc." +50R115,RCF,48,Turner Retirement Homes,5405 Boise Street,"Turner, OR 97392",,"Turner Retirement Homes, Inc.","Turner Retirement Homes, Inc." +50R121,RCF,150,West Hills Village Senior Residence,5711 SW Multnomah Blvd,"Portland, OR 97219",,West Hills Village Limited Partnership,"West Hills Village, LP" +50R125,RCF,60,Willson House Residential Care Facility,1625 Center St NE,"Salem, OR 97301",,United Methodist Retirement Center Inc.,"Concepts in Community Living, Inc." +50R126,RCF,40,Regency Woodland,4710 Sunnyside Rd SE,"Salem, OR 97302",,"BD Salem I, LLC","Regency Pacific Management, LLC" +50R128,RCF,70,Cascades of Bend Retirement Community,1801 NE Lotus Dr,"Bend, OR 97701",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +50A034,RCF,122,Farmington Square - Salem,910 Boone Rd SE,"Salem, OR 97306",,"RSL Salem, LLC","Radiant Senior Living, Inc." +50A070,RCF,49,Regency Park Alzheimer's Care,8300 SW Barnes Rd,"Portland, OR 97225",,Regency Park Apartments Ltd Part.,"Regency Park Management, LLC" +50A074,RCF,42,Holly Residential Care Center,1075 Irvington Drive,"Eugene, OR 97404",,The Maren Corporation,The Maren Corporation +50A083,RCF,81,Farmington Square - Medford,1530 Poplar Dr,"Medford, OR 97504",,"RSL Medford, LLC","Radiant Senior Living, Inc." +50A143,RCF,64,Farmington Square - Tualatin,17950 SW 115th Ave,"Tualatin, OR 97062",,"RSL Tualatin, LLC","Radiant Senior Living, Inc." +50A149,RCF,66,Farmington Square - Eugene,2730 Bailey Lane,"Eugene, OR 97401",,"RSL Eugene, LLC","Radiant Senior Living, Inc." +50A165,RCF,32,"Regent at Sheldon Park, a Blue Harbor Senior Living Community",2440 Willakenzie Road,"Eugene, OR 97401",,Sheldon Park Management LLC,Sheldon Park Management LLC +50A214,RCF,48,Monterey Court Memory Care,8915 SE Monterey,"Happy Valley, OR 97086",,"Monterey Court Ventures, LLC","Frontier Management, LLC" +50A219,RCF,20,Expressions at Summerplace,15727 NE Russell Street,"Portland, OR 97230",,"Summerplace Assisted Living, LLC","Prestige Senior Living, L.L.C" +50A226,RCF,30,Settler's Park Memory Care Community,2895 17th Street,"Baker City, OR 97814",,LSREF Golden Ops 26 (OR) LLC,"SLH Rainier Manager, LLC" +50A232,RCF,60,Brookdale Beaverton,16655 NW Walker Rd,"Beaverton, OR 97006",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50R139,RCF,40,Clackamas View Senior Living - Milwaukie,14550 SE Vista Ln,"Milwaukie, OR 97267",,"Chancellor Health Care of California X, Inc.","Chancellor Health Care, Inc," +50R145,RCF,17,Horton Plaza,1122 Spring St,"Medford, OR 97504",,Horton Plaza A Joint Venture,"Dharma Healthcare Management, Inc." +50R171,RCF,16,Oaktree Residential Living,5030 West Port St PO Box 22636,"Eugene, OR 97402",,Elman's House Corp.,Elman's House Corp. +50R200,RCF,22,Willamette Lutheran Retirement Community,7693 Wheatland Rd,"Salem, OR 97308",,"Willamette Lutheran Homes, Inc.","Willamette Lutheran Homes, Inc." +50R202,RCF,20,Riverview Terrace,1970 West Harvard Avenue,"Roseburg, OR 97470",,Crown One Development LLC,"Crown Two Development, LLC" +50R216,RCF,102,Capital Manor Retirement Community,1955 Salem Dallas Hwy NW,"Salem, OR 97304",,"Capital Manor, Inc.","Life Care Services, LLC" +50R229,RCF,96,Willamette View Terrace,13169 SE River Road,"Portland, OR 97222",,"Willamette View, Inc. dba","Willamette View, Inc." +50R230,RCF,44,Holladay Park Plaza,1300 NE 16th,"Portland, OR 97232",,"Holladay Park Plaza, Inc.","Pacific Retirement Services, Inc." +50R234,RCF,38,"Springs at Anna Maria, The",822 Golf View Drive,"Medford, OR 97504",,"HSRE-Springs III at Medford AM sub-TRS, LLC","The Springs Living, LLC" +50R251,RCF,16,Ivy Court Senior Living,18265 SE River Road,"Milwaukie, OR 97222",,"Ivy Court Senior Living, Inc.","Ivy Court Senior Living, Inc." +50R256,RCF,15,Elite Care Oatfield Estates-Hood House,4499 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" +50R270,RCF,70,Rose Linn Vintage Place,2330 Debok Rd,"West Linn, OR 97068",,West Linn Care Center Operating Co LLC,"Benecia Senior Living, LLC" +50R271,RCF,21,Willamette View Memory Care Community,13145 SE River Rd,"Portland, OR 97222",,"Willamette View, Inc.","Willamette View, Inc." +50R273,RCF,27,Suttle Care & Retirement,1601 SW 24th St.,"Pendleton, OR 97801",,"Suttle Care & Retirement, Inc.","Suttle Care & Retirement, Inc." +50R274,RCF,11,Ashley Manor - Arrowhead,3853 Arrowhead Dr.,"Medford, OR 97504",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50R275,RCF,28,Avamere at St. Helens,2400 Gable Rd.,"St. Helens, OR 97051",,"Avamere - St. Helens Operations, LLC","Avamere-St. Helens Operations, LLC " +50R276,RCF,27,Edgewood Arbor Memory Care,7733 SW Scholls Ferry Rd.,"Beaverton, OR 97008",,"Beaverton Assisted Living, LLC","Hawthorn Retirement Group, LLC" +50R277,RCF,20,Courtyard at Hillside Memory Care,300 NW Hillside Park Way,"McMinnville, OR 97128",,Emeritus Corporation,Emeritus Corporation +50R278,RCF,25,Manor Special Care Center,1200 Mira Mar Ave.,"Medford, OR 97504",,"Rogue Valley Manor, Inc.","Pacific Retirement Services, Inc." +50R279,RCF,64,Brookdale Eugene Alpine Court Memory Care,3720 N. Clarey St,"Eugene, OR 97402",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +50R280,RCF,48,Elderberry Square Community,3321 Oak St,"Florence, OR 97439",,"Elderberry Square Community, LLC","Senior Housing Managers, LLC" +50R281,RCF,15,Ashley Manor - Conners,2853 NE Conners Ave.,"Bend, OR 97701",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50R282,RCF,15,Elite Care Oatfield Estates-Adam's House,4483 SE Oatfield Hill Rd,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" +50R283,RCF,35,Countryside Living of Canby,390 NW 2nd,"Canby, OR 97013",,"Countryside Living of Canby, LLC","Countryside Living of Canby, LLC" +50R285,RCF,18,West Wind Court,465 4th St. SW,"Bandon, OR 97411",,West Wind Court Corporation,West Wind Court Corporation +50R287,RCF,21,Raleigh Hills Enhanced Care Community,4815 SW Dogwood Ln,"Portland, OR 97225",,"Raleigh Hills Management, LLC","Raleigh Hills Management, LLC" +50R288,RCF,15,Ashley Manor - Athens,1514 Athens Ave.,"Pendleton, OR 97801",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50R289,RCF,15,Elite Care Oatfield Estates-Helen's House,4469 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" +50R290,RCF,48,Rosewood Specialty Care,2550 SE Century Blvd.,"Hillsboro, OR 97123",,"Brookwood Court Assisted Living, LLC","Hillsboro Care Properties, LLC" +50R292,RCF,43,Quail Park of Klamath Falls,1000 Town Center Dr.,"Klamath Falls OR, OR 97601",,"Quail Park of Klamath Falls, LLC",Living Care Lifestyles +50R293,RCF,186,Miramont Pointe,11520 SE Sunnyside Rd,"Clackamas, OR 97015",,"MP, LLC","MP, LLC" +50R294,RCF,142,Hearthstone at Murrayhill,10880 SW Davies Rd.,"Beaverton, OR 97008",,"Hearthstone at Murrayhill, LLC","Hearthstone Management Services, LLC" +50R295,RCF,15,Ashley Manor - Anique,525 Anique Ln,"Grants Pass, OR 97526",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50R296,RCF,40,Avamere at Seaside Residential Care Facility,2500 S. Roosevelt Dr.,"Seaside, OR 97138",,"Necanicum Operations, LLC","Necanicum Operations, LLC" +50R297,RCF,18,Prestige Senior Living Orchard Heights Memory Care,695 Orchard Heights Rd. NW,"Salem, OR 97304",,CHP Salem-Orchard Heights OR Tenant Corp.,"Prestige Senior Living, LLC" +50R298,RCF,16,Sweet Bye N Bye,2480 Coral Ave NE,"Salem, OR 97305",,"Sweet Bye N Bye AFC & RCF Facilities, Inc.","Sweet Bye N Bye AFC & RCF Facilities, Inc." +50R300,RCF,15,Hawthorne House of Salem,3042 Hyacinth St. NE,"Salem, OR 97303",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R301,RCF,55,Emerson House,3577 SE Division,"Portland, OR 97202",,"Emerson House, LLC","Kinsel Ameri Properties, Inc." +50R302,RCF,48,Timberwood Court Specialty Care Community,2875 SE 14th Ave,"Albany, OR 97321",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" +50R303,RCF,16,SpringRidge Court Memory Care,32100 SW French Prairie Rd,"Wilsonville, OR 97070",,Spring Ridge Subtenant LLC,"SRG Management, LLC" +50R304,RCF,90,Gateway Gardens,178 Commons Dr.,"Eugene, OR 97401",,"Gateway Gardens Assisted Living, Inc.","Gateway Gardens Assisted Living, Inc." +50R305,RCF,52,Evergreen Court of Molalla,250 Kennel St.,"Molalla, OR 97038",,"Molalla Senior Living, LLC","Avant Senior Housing Managers & Consultants, LLC" +50R306,RCF,15,Ashley Manor - Homedale,44 North Homedale Rd.,"Klamath Falls, OR 97601",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +50R307,RCF,13,"Touch of Grace, A","PO Box 165, 2156 Brookhurst St.","Medford, OR 97504",,"A Touch of Grace, LLC","A Touch of Grace, LLC" +50R308,RCF,15,Elite Care Oatfield Estates-Rainier House,4457 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" +50R309,RCF,16,Silvia & John's Residential Care,19909 SE Stark St.,"Portland, OR 97233",,"Silvia & John's Residential Care, Inc.","Silvia & John's Residential Care, Inc." +50R310,RCF,50,Rosewood Court Residential Care,4254 Weathers Street NE,"Salem, OR 97301",,"Capri Senior Living, LLC","Capri Senior Living , LLC" +50R311,RCF,43,"Gardens, The",2690 NE Yacht,"Lincoln City, OR 97367",,"Lakeview Operations, LLC","Westmont Living, Inc." +50R313,RCF,18,Prairie House Memory Care Community,51485 Morson St.,"La Pine, OR 97739",,"Assisted Living Alternatives, Inc.",Ridgeline Management Co. +50R314,RCF,15,Magnolia Village Memory Care Community,1355 Daugherty,"Cottage Grove, OR 97424",,"Magnolia Village, LLC","Magnolia Gardens, LLC" +50R315,RCF,16,All Comfort Residential Care,9347 SW 35th St.,"Portland, OR 97219",,"Peaks and Valleys, LLC","Peaks and Valleys, LLC" +50R316,RCF,64,Hope N Care,12045 SE Pardee St.,"Portland, OR 97266",,"Asa Care, Inc.","Asa Care, Inc." +50R318,RCF,15,Elite Care Oatfield Estates-Jefferson House,4422 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" +50R319,RCF,15,"Golden Age Living, LLC",3484 SE Hill Rd.,"Milwaukie, OR 97267",,Golden Age Living LLC,Golden Age Living LLC +50R320,RCF,26,Avamere at Bethany,16360 NW Avamere Court,"Portland, OR 97229",,"Avamere Bethany Operations, LLC","Avamere Bethany Operations, LLC" +50R321,RCF,42,Providence ElderPlace in Cully,5119 NE 57th Ave.,"Portland, OR 97218",,Providence Health & Services - Oregon,Providence Health & Services - Oregon +50R322,RCF,23,Mountain View Residential Care Facility,1220 SE 282nd Ave.,"Gresham, OR 97080",,"BME Enterprises, Inc.",Fred T. & Elizabeth C. Asa +50R323,RCF,18,Prestige Senior Living Arbor Place Memory Care,3150 Juanipero Way,"Medford, OR 97504",,CHP Medford -Arbor Place OR Tenant Corp.,"Prestige Senior Living, L.L.C" +50R326,RCF,16,West Wind Enhanced Care,3130 Juanipero St.,"Medford, OR 97504",,"Ashland View Manor, Inc.","Ashland View Manor, Inc." +50R327,RCF,33,"Atrium at Flagstone, The",3325 Columbia View Dr.,"The Dalles, OR 97058",,"Flagstone Operations, LLC.","Milestone Retirement Communities, LLC" +50R328,RCF,15,Arbor House of Grants Pass,820 Gold Court,"Grants Pass, OR 97527",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R330,RCF,15,Elite Care Oatfield Estates-Ashland House,4398 SE Oatfield Hill Rd.,"Milwaukie, OR 97267",,"Elite Care Oatfield Estates, LLC","Elite Care Management Group, LLC" +50R331,RCF,20,Dallas Retirement Village Memory Care Center,340 NW Brentwood Avenue,"Dallas, OR 97338",,"Dallas Health Care Center, LLC",Life Care Services +50R332,RCF,15,Heritage House of Woodburn,943 N. Cascade Dr.,"Woodburn, OR 97071",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R333,RCF,56,Laurel Pines Retirement Lodge,3100 Avenue A,"White City, OR 97503",,"Laurel Pines, Inc.","Dakavia Management, Corp." +50R334,RCF,16,East Cascade Memory Care Community,175 NE 16th Street,"Madras, OR 97741",,"East Cascade Retirement Community, LLC","Senior Housing Managers, LLC" +50R336,RCF,31,Oswego Grove,4550 SW Carman Drive,"Lake Oswego, OR 97035",,"Avamere Lake Oswego Operations Investors, LLC","Avamere Lake Oswego Operations Investors, LLC" +50R339,RCF,15,Angeline Senior Living,501 3rd St.,"La Grande, OR 97850",,"Angeline Senior Living, LLC","Angeline Senior Living, LLC" +50R340,RCF,30,Fanno Creek by Elite Care,12353 SW Grant St,"Tigard, OR 97223",,"Elite Care Grant, LLC","Elite Care Management Group, LLC" +50R343,RCF,15,Autumn House of Grants Pass,PO Bx 1419 2268 Williams Hwy,"Grants Pass, OR 97528",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R344,RCF,32,Brookdale Redmond Clare Bridge,1942 SW Canyon Drive,"Redmond, OR 97756",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +50R345,RCF,36,Middlefield Oaks Memory Care Community,1500 Village Drive,"Cottage Grove, OR 97424",,"Middlefield Oaks Assisted Living, LLC",Frontline Management +50R346,RCF,16,Cornerstone Residential Option,12640 SE Bush,"Portland, OR 97236",,"Cornerstone Care Option, Inc","Cornerstone Care Option, Inc." +50R347,RCF,14,Bayberry Commons Memory Care,2211 Laura Street,"Springfield, OR 97477",,"Bayberry Commons, Inc.",Ridgeline Management Co. +50R348,RCF,22,Rock of Ages Mennonite Home,15600 SW Rock of Ages Rd.,"McMinnville, OR 97128",,"Bible Mennonite Fellowship, Inc.","Bible Mennonite Fellowship, Inc." +50R349,RCF,95,Touchmark at Mt. Bachelor Village,19800 SW Touchmark Way,"Bend, OR 97702",,"Touchmark at Mt. Bachelor Village, LLC","Touchmark Living Centers, Inc." +50R350,RCF,21,Hawthorne Gardens Memory Care Community,2828 SE Taylor Street,"Portland, OR 97214",,"GF Hawthorne Tenant, LLC","Artegan at Hawthorne Gardens, LLC" +50R351,RCF,45,Chantele's Loving Touch Memory Care,1128 W. Central Avenue,"Sutherlin, OR 97479",,"Chantele's Loving Touch Memory Care, Inc.","Chantele's Loving Touch Memory Care, Inc." +50R352,RCF,12,Pheasant Pointe Memory Care Community,835 E. Main Street,"Molalla, OR 97038",,"ARHC PPMOLOR01 TRS, LLC","FM Pheasant Pointe, LLC" +50R353,RCF,24,Cedar Village Memory Care Community,4452 Lancaster Drive NE,"Salem, OR 97301",,"ARHC CVSALOR01 TRS, LLC","FM Cedar Village, LLC" +50R355,RCF,16,Riverside Living,23500 NE Halsey St.,"Wood Village, OR 97060",,"Riverside Living, Inc.","Riverside Living, Inc." +50R356,RCF,15,Harmony House of Salem,3062 Hyacinth St. NE,"Salem, OR 97301",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R357,RCF,28,McLoughlin Memory Care,1145 Molalla Avenue,"Oregon City, OR 97045",,"McLoughlin Place Operations, LLC","Milestone Retirement Communities, LLC" +50R358,RCF,52,Fircrest Memory Care,213 NE Fircrest Drive,"McMinnville, OR 97128",,"Fircrest Community Living, Inc.","Fircrest Community Living, Inc." +50R359,RCF,25,Spruce Point Memory Care,375 9th Street,"Florence, OR 97439",,"Spruce Point, Inc.",Prestige Care Inc. +50R360,RCF,20,Russellville Park West Memory Care,23 SE 103rd,"Portland, OR 97216",,"Russellvillle III, LLC","Leisure Care, LLC" +50R361,RCF,12,Footsteps at Tanasbourne,1950 NW 192nd Avenue,"Hillsboro, OR 97006",,"Springs at Tanasbourne II, LLC","The Springs Living, LLC" +50R363,RCF,30,Manor Terrace Care Suites,1250 Mira Mar Avenue,"Medford, OR 97504",,Rogue Valley Manor,"Pacific Retirement Services, Inc." +50R364,RCF,8,Summit Springs Village MCU,120 S. Church St.,"Condon, OR 97823",,Summit Springs Village Corporation,Summit Springs Village Corporation +50R365,,,Churchill Estates Residential Care,3800 Westleigh,"Eugene, OR 97405",,"Churchill Management, Inc.","Churchill Retirement Services, LLC" +50R366,RCF,44,Tanner Spring Memory Care,23000 Horizon Drive,"West Linn, OR 97068",,Sequoia Heights Capital Partners,"TS Management, LLC" +50R367,RCF,48,Arbor Oaks Terrace Memory Care,317 Werth Blvd.,"Newberg, OR 97132",,"Newberg Memory Associates, LLC","Frontier Management, LLC" +50R368,RCF,35,Brightcreek at Sea View,98059 Gerlach Lane,"Brookings, OR 97415",,"Sea View Assisted Living Community, LLC","Seasons Management, LLC" +50R369,RCF,40,Hillside Care Manor,800 NW 25th Avenue,"Portland, OR 97210",,"Peaks and Valleys, LLC","Peaks and Valleys, LLC" +50R370,RCF,16,Roxy Ann Memory Community,2530 Lone Pine Road,"Medford, OR 97504",,"Roxy Ann Memory Community, LLC","Roxy Ann Memory Community, LLC" +50R371,RCF,15,Applegate House of Grants Pass,1635 Kellenbeck Avenue,"Grants Pass, OR 97528",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R372,RCF,16,Kinsington Place,827 SW Kinsington Court,"Grants Pass, OR 97526",,"Heirloom Living Centers, LLC","Heirloom Living Centers, LLC" +50R373,RCF,20,Silver Creek Memory Care Community,703 Evergreen Rd.,"Woodburn, OR 97071",,"FC Ranger OPS Silver Creek(OR), LLC","Silver Creek Care Properties, LLC" +50R374,RCF,40,Revere Court of Portland,11547 NE Glisan Street,"Portland, OR 97220",,"Chancellor Health Care of California X, Inc.","Chancellor Health Care, Inc," +50R375,RCF,45,RN Villa Care Center,401 NE 139th Avenue,"Portland, OR 97230",,"RN Villa Care Center, LLC","RN Villa Care Center, LLC" +50R376,RCF,22,Hawthorne House,2635 21st Avenue,"Forest Grove, OR 97116",,"Hawthorne House, LLC","Caring Places Management, LLC" +50R377,RCF,32,Footsteps at Clackamas Woods,14314 SE Webster Road,"Milwaukie, OR 97267",,"TSL Clack OPS, LLC","The Springs Living, LLC" +50R378,RCF,60,Adara Oaks Manor,931 NE Linden Avenue,"Gresham, OR 97030",,"Adara Oaks Manor, LLC","Adara Oaks Manor, LLC" +50R379,RCF,84,Fern Gardens Memory Care,2636 Table Rock Rd,"Medford, OR 97504",,"Fern Gardens Memory Care, LLC",Ridgeline Management Co. +50R380,RCF,20,Countryside Living South,406 NW 2nd Avenue,"Canby, OR 97013",,"Countryside Living of Canby, LLC","Countryside Living of Canby, LLC" +50R381,RCF,16,Maryville Memory Care,14645 SW Farmington Road,"Beaverton, OR 97007",,Sisters of St. Mary of Oregon Maryville Corp.,Sisters of St. Mary of Oregon Maryville Corp. +50R382,RCF,48,Washington Gardens Memory Care,9000 SW 91st Avenue,"Tigard, OR 97223",,"Tigard Memory Associates, LLC","Frontier Management, LLC" +50R383,RCF,28,Royalton Place Memory Care,5555 SE King Rd,"Milwaukie, OR 97222",,"BDC/Milwaukie, LLC","Royalton Place Management, LLC" +50R384,RCF,20,Senior Haven Residential Care Facility,12140 SE Foster Road,"Portland, OR 97266",,"Senior Haven RCF, LLC","Senior Haven RCF, LLC" +50R385,RCF,24,Bonaventure of Salem Memory Care,3411 Boone Rd SE,"Salem, OR 97317",,"Bonaventure of Salem, LLC",Bonaventure Senior Living +50R386,RCF,7,Thanksgiving House,184 N 2nd St,"St. Helens, OR 97051",,Cecile Molden,Cecile Molden +50R387,RCF,13,"Griffin House, The",6630 Alderbrook Road,"Tillamook, OR 97141",,The Griffin House LLC,The Griffin House LLC +50R388,RCF,10,Gateway 2 Healthier Living,608 N Cloverleaf Loop,"Springfield, OR 97477",,"Gateway Assisted Living, Inc","Gateway Assisted Living, Inc." +50R389,RCF,33,Cherry Park Plaza,1323 SW Cherry Park Road,"Troutdale, OR 97060",,"CHGCXA Troutdale, LLC","CHG Management Company I, LLC" +50R390,RCF,56,Mt. Bachelor Memory Care,20225 Powers Road,"Bend, OR 97702",,"MBMC 1, LLC","Frontier Management, LLC" +50R391,RCF,10,Wallowa Valley Senior Living Memory Care,605 Medical Parkway,"Enterprise, OR 97828",,Wallowa County Health Care District,"Marathon Enterprise, LLC" +50R393,RCF,27,Jennings McCall RCF,2300 Masonic Way,"Forest Grove, OR 97116",,Grand Lodge of AF & AM of Oregon,"Aidan Health Services, Inc." +50R394,RCF,10,Valley View Memory Care,112 Valley View Drive,"John Day, OR 97845",,"Valley View Investors, LLC","Ageia Health Services, LLC" +50R395,RCF,28,Four Seasons RCF Evergreen,2855 Evergreen Ave NE,"Salem, OR 97301",,Four Seasons RCF Evergreen,Four Seasons RCF Evergreen +50R396,RCF,39,Whitewood Gardens,2027 SE 174th Ave.,"Portland, OR 97233",,"Whitewood Group, LLC","Whitewood Group, LLC" +50R397,RCF,31,Footsteps at Sherwood,15677 SW Oregon,"Sherwood, OR 97140",,"HSRE-Springs II at Sherwood Sub-TRS, LLC","The Springs Living, LLC" +50R398,RCF,16,Footsteps at Carman Oaks,3900 SW Carman Drive,"Lake Oswego, OR 97035",,"HSRE-Springs II at Lake Oswego Sub-TRS, LLC","The Springs Living, LLC" +50R399,RCF,25,Footsteps at Mill Creek,1021 W 10th Street,"The Dalles, OR 97058",,"HSRE-Springs II at the Dalles, LLP","The Springs Living, LLC" +50R400,RCF,15,Vista View Mood & Memory Care,4439 Hamrick Rd,"Central Point, OR 97502",,Kathleen Howard,Kathleen Howard +50R401,RCF,26,Marie Rose Residential Care,17360 Holy Names Drive,"Lake Oswego, OR 97034",,"Mary's Woods at Marylhurst, Inc.","Mary's Woods at Marylhurst, Inc." +50R402,RCF,18,Grace Manor,2811 Bailey Lane,"Eugene, OR 97401",,"Grace Manor Lease Interests, LL","Senior Housing Managers, LLC" +50R403,RCF,44,Brookdale Geary Street Memory Care,2445 Geary St SE,"Albany, OR 97321",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +50R404,RCF,32,Coral Springs Residential Care,2520 Coral Ave. NE,"Salem, OR 97305",,"Sweet Bye N Bye AFC & RCF Facilities, Inc.","Sweet Bye N Bye AFC & RCF Facilities, Inc." +50R405,RCF,15,Elite Care Oatfield Estates Larch House,4405 SE Oatfield Hill Rd,"Milwaukie, OR 97267",,"Elite Care OE2, LLC","Elite Care OE2, LLC" +50R406,RCF,15,Elite Care Oatfield Estates Tabor House,4425 SE Oatfield Hill Rd,"Milwaukie, OR 97267",,Elite Care OE2 LLC,"Elite Care OE2, LLC" +50R407,RCF,15,Bartlett House of Medford Memory Care Community,3465 Lone Pine Rd,"Medford, OR 97504",,"Pacific Living Centers, Inc.","Pacific Living Centers, Inc." +50R408,RCF,15,Bee Hive Homes of Baker City,3078 Resort St.,"Baker City, OR 97814",,"The Home Place in Baker, LLC",Bee Hive Homes of Baker City +50R409,RCF,48,Heartwood Place,2325 Boones Ferry Road,"Woodburn, OR 97071",,WMC Operating Company LLC,"Benicia Senior Living, LLC" +50R410,RCF,21,McKenzie Living,"6452 ""A"" Street","Springfield, OR 97478",,"McKenzie Living, Inc.","McKenzie Living, Inc. " +50R411,RCF,64,Waterford Grand Memory Care,600 Waterford Way,"Eugene, OR 97401",,"BDC/EUGENE, LLC",BPM Senior Living Company +50R412,RCF,16,Sunset Estates,281 Sunset Dr.,"Ontario, OR 97914",,"CARE 3, LLC","CARE 3, LLC" +50R413,RCF,38,Parkview Memory Care at Cherrywood Village,10721 SE Cherry Blossom Dr.,"Portland, OR 97216",,"PAR, LLC","PAR, LLC" +50R414,RCF,48,"Arbor at Avamere Court, The",450 Claggett Court N,"Keizer, OR 97303",,"Keizer River Operations, LLC","Keizer River Operations, LLC" +50R416,RCF,56,"Cherrywood Memory Care, The",2750 NE Doran Drive,"McMinnville, OR 97128",,"Cherrywood, Inc., The","Cherrywood, Inc., The" +50R417,RCF,34,Advocate Care,13033 South East Holgate Blvd,"Portland, OR 97236",,"Advocate Care, LLC","Advocate Care, LLC" +50R418,RCF,64,Windsong at Eola Hills,2030 Wallace Road NW,"Salem, OR 97304",,"West Salem Memory Care, LLC","Aidan Health Services, Inc." +50R421,RCF,32,Clatsop Care Memory Community,2219 SE Dolphin Road,"Warrenton, OR 97146",,Clatsop Care Center Health District,Clatsop Care Center Health District +50R430,RCF,23,Bonaventure of Albany Memory Care,420 Geri Street,"Albany, OR 97321",,Mountain West Retirement Corporation,Bonaventure Senior Living +50R432,RCF,23,Bonaventure of Tigard Memory Care,15000 SW Hall Blvd,"Tigard, OR 97224",,"Bonaventure of Tigard, LLC",Bonaventure Senior Living +50R433,RCF,68,Waterhouse Ridge Memory Care Community,1115 NW 158th Avenue,"Beaverton, OR 97006",,"Waterhouse Ridge Memory Care, LLC",Frontline Management +5MA003,RCF,40,Ashley Manor - Sage,1355 SW Sage,"Hermiston, OR 97838",,"Ashley Manor, LLC","Ashley Manor, L.L.C." +5MA016,RCF,15,Clarendon Court Alzheimer's Residence,5732 SE 122nd Ave,"Portland, OR 97236",,"Clarendon Court Alzheimer's Residence, LLC","Clarendon Court Alzheimer's Residence, LLC" +5MA024,RCF,62,Curry Manor,1458 Quail Lane,"Roseburg, OR 97470",,"TSL Curry Manor, LLC","Tierra Senior Living, LLC" +5MA031,RCF,76,Farmington Square - Gresham,1655 NE 18th,"Gresham, OR 97030",,"RSL Gresham, LLC","Radiant Senior Living, Inc." +5MA042,RCF,130,Gateway Living,611 N Cloverleaf Loop,"Springfield, OR 97477",,"Gateway Assisted Living, Inc","Gateway Assisted Living, Inc." +5MA043,RCF,102,Providence ElderPlace in Glendoveer,13007 NE Glisan St,"Portland, OR 97230",,Providence Health & Services - Oregon,Providence Health & Services - Oregon +5MA051,RCF,40,Harvest Homes RCF,6921 N Roberts,"Portland, OR 97203",,"Harvest Homes, Inc.","Harvest Homes, Inc." +5MA080,RCF,28,Lydia's House,5353 SE Columbus St,"Albany, OR 97321",,"Mennonite Home Of Albany, Inc.","Mennonite Home Of Albany, Inc." +5MA106,RCF,65,Southtowne Living Center,360 W 28th,"Eugene, OR 97405",,"Eugene Southtowne Living Center, LLC","Ageia Health Services, LLC" +5MA107,RCF,85,St. Andrews Memory Care,7617 SE Main St,"Portland, OR 97215",,"Pacifica Senior Living, LLC","Pacifica Senior Living, LLC" +5MA130,RCF,15,Brookdale McMinnville City Center Memory Care,721 NE 27th St.,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +5MA131,RCF,48,Pelican Pointe Memory Care Community,615 Washburn Way,"Klamath Falls, OR 97603",,"ARHC PPKLAOR01 TRS, LLC","FM Pelican, LLC" +5MA137,RCF,30,Pacific View Memory Care Community,1000 6th Ave West,"Bandon, OR 97411",,"Bandon Senior Living, LLC","Seasons Management, LLC" +5MA146,RCF,110,Brookdale Forest Grove,3110 19th Ave,"Forest Grove, OR 97116",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +5MA151,RCF,57,Brookstone Alzheimer's Special Care Center,5881 SE Woodside Dr,"Salem, OR 97301",,Salem Associates LLC,"Jerry Erwin Associates, Inc." +5MA160,RCF,114,Pacifica Senior Living Portland,1808 SE 182nd Ave,"Portland, OR 97233",,"Pacifica Senior Living, LLC","Pacifica Senior Living, LLC" +5MA161,RCF,32,Skylark Memory Care,950 Skylark Place,"Ashland, OR 97520",,"Ashland Assisted Living, LLC","Mission Senior Living, LLC" +5MA162,RCF,50,"Atrium at McLoughlin Place, The",1153 Molalla Ave,"Oregon City, OR 97045",,"McLoughlin Place Operations, LLC","Milestone Retirement Communities, LLC" +5MA166,RCF,14,Ashley Manor - Alameda,1310 SW 12th Ave,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +5MA170,RCF,37,Brookdale McMinnville Westside,320 SW Hill Road,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +5MA205,RCF,60,Brookdale Salem,1355 Boone Rd SE,"Salem, OR 97302",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +5MA206,RCF,10,Ashley Manor - Well Springs,2110 SW 2nd Avenue,"Ontario, OR 97914",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +5MA207,RCF,56,Cedar Crest Alzheimer Special Care,18325 SW Pacific HWY,"Tualatin, OR 97062",,"Tualatin Associates, LLC",JEA Senior Living +5MA213,RCF,42,Powell Valley Memory Care Community,4001 SE 182nd Ave,"Gresham, OR 97030",,PVALC-LLC,"Care Wise Management, Inc." +5MA215,RCF,55,Baycrest Memory Care,955 Kentucky Avenue,"Coos Bay, OR 97420",,"Bay Area Properties, LLC","Radiant Senior Living, Inc." +5MA217,RCF,51,Footsteps at The Wilsonville,7600 Vlahos Drive,"Wilsonville, OR 97070",,"HSRE-Springs at Wilsonville Sub-TRS, LLC","The Springs Living, LLC" +5MA221,RCF,42,Aspen Ridge Memory Care,1025 NE Purcell Blvd,"Bend, OR 97701",,"FM Aspen MC, LLC","Frontier Management, LLC" +5MA222,RCF,55,Ocean Park,984 Parkview Drive,"Brookings, OR 97415",,"ARHC OPBROOR01 TRS, LLC",Ocean Park Care Properties +5MA223,RCF,60,Pacific Gardens Alzheimer's Special Care Center,17309 NE Glisan,"Portland, OR 97230",,"Erwin Family Properties II, LLC",JEA Senior Living +5MA233,RCF,30,Ashley Manor - Roseburg,427 SE Ramp St.,"Roseburg, OR 97470",,Ashley Manor LLC,Ashley Manor LLC +5MA238,RCF,15,Ashley Manor - Meadow Lakes,228 SW Meadow Lakes Drive,"Prineville, OR 97754",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +5MA240,RCF,48,Callahan Court Memory Care Comm.,1770 NW Valley View Drive,"Roseburg, OR 97470",,LSREF Golden Ops 14(OR) LLC,"Frontier Management, LLC" +5MA241,RCF,15,Ashley Manor - Oak,572 NE Oak Street,"Madras, OR 97741",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +5MA242,RCF,56,"Gardens Enhanced Care Community, The",3334 22nd Ave,"Forest Grove, OR 97116",,"The Grove Assisted Living, L.L.C.","Heights Management, Inc." +5MA243,RCF,79,Quail Park Memory Care Residences,2630 Lone Oak Way,"Eugene, OR 97404",,"Laurel Court of Eugene, LLC",Living Care Management +5MA245,RCF,24,Avamere at Sherwood,16500 SW Century Drive,"Sherwood, OR 97140",,"Avamere Sherwood Operations, LLC","Avamere-Sherwood Operations, LLC" +5MA246,RCF,14,Ashley Manor - Brookhurst,2146 Brookhurst,"Medford, OR 97504",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +5MA249,RCF,24,Avamere at Sandy,17727 SE Langensand Rd,"Sandy, OR 97055",,"Avamere-Sandy Operations, LLC","Avamere Sandy Operations, LLC" +5MA252,RCF,24,Courtyard at Mt.Tabor Garden House,6323 SE Division,"Portland, OR 97206",,"Courtyard Assisted Members, LLC","Integral Senior Living, LLC" +5MA254,RCF,60,Brookdale Roseburg,3400 NW Edenbower Blvd.,"Roseburg, OR 97470",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +5MA255,RCF,15,Ashley Manor - Heidi Lane,2144 NW Heidi Lane,"Grants Pass, OR 97526",,"Ashley Manor, L.L.C.","Ashley Manor, L.L.C." +5MA259,RCF,22,Avamere at Newberg,730 Foothills Dr.,"Newberg, OR 97132",,"Genesis Newberg Operations Company, LLC","Genesis Newberg Operations Company, LLC" +5MA261,RCF,24,Avamere at Hillsboro,2000 SE 30th Avenue,"Hillsboro, OR 97123",,"Avamere-Hillsboro Operations, LLC","Avamere-Hillsboro Operations, LLC" +5MA266,RCF,30,Wildflower Lodge,508 16th St,"LaGrande, OR 97850",,LSREF Golden Ops 14 (OR) LLC,"SLH Rainier Manager, LLC" +5MA269,RCF,64,Brookdale Grants Pass Pointe,1400 Redwood Circle,"Grants Pass, OR 97527",,"S-H OpCo Spring Pointe, LLC","Brookdale Senior Living Communities, Inc." +5ME119,RCF,95,ElderHealth & Living,382-B South 58th St,"Springfield, OR 97478",,ElderHealth & Living Corporation,ElderHealth & Living Corporation +5ME175,RCF,16,Premier Living Center,5120 SE 118th,"Portland, OR 97266",,"Premier Living Center, Inc.","Premier Living Center, Inc." +5ME248,RCF,16,Harmony Living,1535 SW Shirley Ann Drive,"McMinnville, OR 97128",,"Harmony Living, Inc.","Harmony Living, Inc." +70A011,ALF,105,Canfield Place Retirement Community,14570 SW Hart Rd,"Beaverton, OR 97005",,Canfield Place Rtrmt Comm LLC,"Leisure Care, LLC" +70A012,ALF,21,"Springs at Carman Oaks, The",3900 SW Carman Dr,"Lake Oswego, OR 97035",,"HSRE-Springs II at Lake Oswego Sub-TRS, LLC","The Springs Living, LLC" +70A057,ALF,63,Markham House Retirement Community,10606 SW Capitol Hwy,"Portland, OR 97219",,"PORTMH, LLC","Leisure Care, LLC" +70A062,ALF,45,Brookdale Ashland,548 North Main Street,"Ashland, OR 97520",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A069,ALF,55,Regency Park Place at Corvallis,2595 Jack London St,"Corvallis, OR 97330",,"BD Corvallis I, LLC","Regency Pacific Management, LLC" +70A083,ALF,108,"Sheldon Park Assisted Living, a Blue Harbor Senior Living Community",2440 Willakenzie Road,"Eugene, OR 97401",,Sheldon Park Management LLC,Sheldon Park Management LLC +70A097,ALF,70,Timberhill Place,989 NW Spruce Ave,"Corvallis, OR 97330",,"Vintage Investment Prop., Inc.","Vintage Investment Prop., Inc." +70A102,ALF,38,Well Springs Assisted Living Facility,2104 W Idaho,"Ontario, OR 97914",,C & I Properties LLC,"Milestone Retirement Communities, LLC" +70A200,ALF,85,"Springs at Wilsonville, The",7600 Vlahos Drive,"Wilsonville, OR 97070",,"HSRE-Springs II at Lake Oswego Sub-TRS, LLC","The Springs Living, LLC" +70A209,ALF,64,"Terrace at Laurelhurst Village, The",3120 SE Stark,"Portland, OR 97214",,"Laurelhurst Operations, LLC","Laurelhurst Operations, LLC" +70A214,ALF,147,Jennings - McCall Center,2300 Masonic Way,"Forest Grove, OR 97116",,Grand Lodge of AF & AM of Oregon,"Aidan Health Services, Inc." +70A235,ALF,60,Bonaventure of Albany Assisted Living,420 Geri Street,"Albany, OR 97321",,Mountain West Retirement Corporation,Bonaventure Senior Living +70A246,ALF,64,Terwilliger Terrace Assisted Living Facility,2425 SW 6th Ave.,"Portland, OR 97201",,"Terwilliger Plaza, Inc.","Terwilliger Plaza, Inc." +70A249,ALF,20,Providence Brookside Manor,1550 Brookside Dr.,"Hood River, OR 97031",,Providence Health & Services - Oregon,Providence Health System - Oregon +70A259,ALF,50,Willamette View Neighborhoods,13145 SE River Road,"Portland, OR 97222",,"Willamette View, Inc. dba","Willamette View, Inc." +70A260,ALF,72,Prestige Senior Living Southern Hills,4795 Skyline Rd. S.,"Salem, OR 97306",,CHP Salem-Southern Hills OR Tenant Corp.,"Prestige Senior Living, L.L.C" +70A261,ALF,59,Edgewood Point Assisted Living,7733 SW Scholls Ferry Rd,"Beaverton, OR 97008",,"Beaverton Assisted Living, LLC","Hawthorn Retirement Group, LLC" +70A262,ALF,68,Terrace at Hillside Assisted Living,440 NW Hillside Park Way,"McMinnville, OR 97128",,Emeritus Corporation,Emeritus Corporation +70A263,ALF,53,Shore Pines Assisted Living,93975 Ocean Way,"Gold Beach, OR 97444",,"Shore Pines Assisted Living, LLC","Mosaic Management, Inc." +70A264,ALF,110,Royal Anne Assisted Living Facility,10610 SE Clay St.,"Portland, OR 97216",,"PAR, LLC","Generations, LLC" +70A265,ALF,50,Sea Aire Assisted Living,1882 N Hwy 101,"Yachats, OR 97498",,"Sea Aire Assisted Living, LLC","Sea Aire Assisted Living, LLC" +70A266,ALF,77,"Bridge Assisted Living, The",201 SW Bridge St.,"Grants Pass, OR 97526",,"Grants Pass Assisted Living, LLC","Woollard Ipsen Management, LLC" +70A267,ALF,96,Vineyard Heights Assisted Living & Retirement Cottages,345 SW Hill Rd.,"McMinnville, OR 97128",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" +70A268,ALF,90,Raleigh Hills Assisted Living Community,4815 SW Dogwood Ln,"Portland, OR 97225",,"Raleigh Hills Management, LLC","Raleigh Hills Management, LLC" +70A269,ALF,85,Hawks Ridge Senior Assisted Living Community,1795 8th St,"Hood River, OR 97031",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" +70A270,ALF,100,Somerset Assisted Living,8360 Cason Rd,"Gladstone, OR 97027",,Gladstone Assisted Living LLC,"Hawthorn Retirement Group, LLC" +70A271,ALF,130,Providence ElderPlace in Irvington Village,420 NE Mason,"Portland, OR 97211",,Providence Health & Services - Oregon,Providence Health & Services - Oregon +70A273,ALF,80,Hearthstone at Murrayhill Assisted Living,10880 SW Davies Rd,"Beaverton, OR 97008",,"Hearthstone at Murrayhill, LLC","Hearthstone Management Services, LLC" +70A274,ALF,95,Stoneybrook Assisted Living,4650 SW Hollyhock Circle,"Corvallis, OR 97333",,"Corvallis Assisted Living, LLC","Hawthorn Retirement Group, LLC" +70A275,ALF,64,Avamere at Seaside,2500 S. Roosevelt Dr.,"Seaside, OR 97138",,"Necanicum Operations, LLC","Necanicum Operations, LLC" +70A276,ALF,57,"Springs at Sherwood, The",15677 SW Oregon,"Sherwood, OR 97140",,"HSRE-Springs at Sherwood Sub-TRS, LLC","The Springs Living, LLC" +70A277,ALF,67,Prestige Senior Living Orchard Heights,695 Orchard Heights Rd NW,"Salem, OR 97304",,CHP Salem -Orchard Heights OR Tenant Corp,"Prestige Senior Living, LLC" +70A278,ALF,84,Assumption Village,9121 N. Burr Avenue,"Portland, OR 97203",,Assumption Village LLC,S.A.G.E. +70A279,ALF,82,Prestige Senior Living Five Rivers,3500 12th St,"Tillamook, OR 97141",,CHP Tillamook-Five Rivers OR Tenant Corp,"Prestige Senior Living, LLC" +70A280,ALF,55,Corvallis Caring Place Assisted Living,750 NW 23rd St,"Corvallis, OR 97330",,"Corvallis Caring Place, Inc.","Mennonite Management Services, Inc." +70A281,ALF,72,Prestige Senior Living West Hills,5595 SW West Hills Rd.,"Corvallis, OR 97333",,"CHP-Corvallis-West Hills OR Tenant, Inc.",Prestige Senior Living +70A283,ALF,18,Willow Creek Terrace,400 Frank Gilliam Dr.,"Heppner, OR 97836",,Willow Creek Valley Assisted Living Corp.,Morrow County Health District +70A284,ALF,85,SpringRidge Court Assisted Living,32100 SW French Prairie Rd.,"Wilsonville, OR 97070",,Spring Ridge Subtenant LLC,"SRG Management, LLC" +70A285,ALF,50,Country Meadows Village,155 S. Evergreen,"Woodburn, OR 97071",,"Crown II Development, LLC","Crown Two Development, LLC" +70A286,ALF,72,Marquis Wilsonville Assisted Living,30900 SW Parkway Ave,"Wilsonville, OR 97070",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +70A287,ALF,40,"Amber Assisted Living, The",365 SW Bel Air Drive- PO Box 308,"Clatskanie, OR 97016",,"Amber Investors, LLC","Ageia Health Services, LLC" +70A288,ALF,80,Marquis Piedmont Assisted Living,319 NE Russet St.,"Portland, OR 97211",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +70A289,ALF,75,Prestige Senior Living High Desert,2660 NE Mary Rose Place,"Bend, OR 97701",,CHP Bend-High Desert OR Tenant Corp.,"Prestige Senior Living, LLC" +70A290,ALF,78,Brookdale Chestnut Lane - Gresham,1219 NE Sixth Street,"Gresham, OR 97030",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A291,ALF,90,Avamere at Bethany Assisted Living Facility,16360 NW Avamere Court,"Portland, OR 97229",,"Avamere Bethany Operations, LLC","Avamere-Bethany Operations, LLC" +70A292,ALF,64,Prestige Senior Living Arbor Place,3150 Juanipero Way,"Medford, OR 97504",,CHP Medford -Arbor Place OR Tenant Corp.,"Prestige Senior Living, LLC" +70A293,ALF,31,Pioneer Place Assisted Living,1060 D Street W,"Vale, OR 97918",,Pioneer Nursing Home Health District,Pioneer Nursing Home Health District +70A294,ALF,76,Fox Hollow Independent & Assisted Living Community,2599 NE Studio Rd,"Bend, OR 97701",,"Fox Hollow Bend, LLC","Regency Pacific Management, LLC" +70A295,ALF,100,Brookdale Sellwood,8517 SE 17th Avenue,"Portland, OR 97202",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A296,ALF,35,Canyon Rim Manor,1701 George Jackson Rd.,"Maupin, OR 97037",,"Maupin Senior Living, LLC","Mosaic Management, Inc." +70A297,ALF,95,Brookdale Lebanon,181 South 5th Street,"Lebanon, OR 97355",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A298,ALF,60,Pioneer Village,805 N. 5th St.,"Jacksonville, OR 97530",,"RSL Pioneer, LLC","Radiant Senior Living, Inc." +70A299,ALF,150,Brookdale Springfield Briarwood,4865 Main Street,"Springfield, OR 97478",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A300,ALF,44,"Springs at Veranda Park, The",1641 NE Veranda Park Drive,"Medford, OR 97504",,"HSRE-Springs III at Medford VP Sub TRS, LLC","The Springs Living, LLC" +70A301,ALF,69,Bonaventure of Tigard Assisted Living,15000 SW Hall Blvd,"Tigard, OR 97224",,"Bonaventure of Tigard, LLC",Bonaventure Senior Living +70A302,ALF,100,Ocean Ridge Retirement and Assisted Living Community,1855 SE Ocean Blvd.,"Coos Bay, OR 97420",,"ARHC ORCOOOR01 TRS, LLC","FM Ocean Ridge, LLC" +70A303,ALF,82,Brookdale Oswego Springs - Portland,11552 SW Lesser Rd.,"Portland, OR 97219",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A304,ALF,79,Oswego Place Assisted Living Community,17450 Pilkington Rd.,"Lake Oswego, OR 97035",,"Oswego Place Assisted Living Community, LLC",Bonaventure Senior Living +70A305,ALF,77,Brookdale Redmond Assisted Living,1942 SW Canyon Drive,"Redmond, OR 97756",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A306,ALF,85,Middlefield Oaks Assisted Living Community,1500 Village Drive,"Cottage Grove, OR 97424",,"Middlefield Oaks Assisted Living, LLC",Fronline Management +70A307,ALF,62,Bayberry Commons Assisted Living,2211 Laura Street,"Springfield, OR 97477",,"Bayberry Commons, Inc.",Ridgeline Management Co. +70A308,ALF,110,Brookdale Newberg,3802 Hayes St.,"Newberg, OR 97132",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70A309,ALF,65,Hawthorne Gardens Senior Living Community,2828 SE Taylor Street,"Portland, OR 97214",,"GF Hawthorne Tenant, LLC","Artegan at Hawthorne Gardens, LLC" +70A310,ALF,16,"Stafford Assisted Living Facility, The",1200 Overlook Dr,"Lake Oswego, OR 97034",,"Avamere Stafford Operations, LLC","Avamere Stafford Operations, LLC" +70A311,ALF,29,Fircrest Community Living,213 NE Fircrest Drive,"McMinnville, OR 97128",,"Fircrest Community Living, Inc.","Fircrest Community Living, Inc." +70A312,ALF,153,Laurel Parc at Bethany,15850 NW Central Drive,"Portland, OR 97229",,"Laurel Parc AL at Bethany, LLC","Laurel Parc AL at Bethany, LLC" +70A314,ALF,120,Russellville Park West,23 SE 103rd,"Portland, OR 97216",,"Russellvillle III, LLC","Leisure Care, LLC" +70A315,ALF,49,Courtyard Fountains Assisted Living Community,1537 SE 223rd,"Gresham, OR 97030",,"ARHC CFGREOR01 TRS, LLC","Courtyard Fountains Care Properties, LLC" +70A316,ALF,99,Sea View Senior Living Community,98059 Gerlach Lane,"Brookings, OR 97415",,"Sea View Assisted Living Community, LLC","Seasons Management, LLC" +70A317,ALF,24,Mirabella at South Waterfront,3550 SW Bond Ave.,"Portland, OR 97239",,Mirabella at South Waterfront,"Pacific Retirement Services, Inc." +70A318,ALF,22,Countryside Village,1700 Kellenbeck Rd.,"Grants Pass, OR 97528",,"Lynn-Ann Development, LLC","Lynn-Ann Development, LLC" +70A319,ALF,64,Royalton Place Assisted Living,5555 SE King Rd,"Milwaukie, OR 97222",,"BDC/Milwaukie, LLC","Royalton Place Management, LLC" +70A320,ALF,65,Bonaventure of Salem Assisted Living,3411 Boone Rd SE,"Salem, OR 97317",,"Bonaventure of Salem, LLC",Bonaventure Senior Living +70A321,ALF,25,Dallas Retirement Village Assisted Living HUD,377 NW Jasper St,"Dallas, OR 97338",,"Dallas Health Care Center, LLC",Life Care Services +70A322,ALF,19,Wallowa Valley Senior Living,605 Medical Parkway,"Enterprise, OR 97828",,Wallowa County Health Care District,"Marathon Enterprise, LLC" +70A323,ALF,101,Waterford Grand Assisted Living,600 Waterford Way,"Eugene, OR 97401",,"BDC/EUGENE, LLC",BPM Senior Living Company +70A324,ALF,87,Marquis Tualatin Assisted Living,19945 SW Boones Ferry Road,"Tualatin, OR 97062",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +70M001,ALF,40,Adams House Assisted Living,121 Cordelia Drive,"Myrtle Creek, OR 97457",,"Assisted Living Facilities, Inc.","Concepts in Community Living, Inc." +70M002,ALF,64,Alderwood Assisted Living,131 Alder St,"Central Point, OR 97502",,"Alderwood Assisted Living, LLC","AIM Senior Management, LLC" +70M003,ALF,36,Alpine House Assisted Living,204 N Park St,"Joseph, OR 97846",,"Joseph ALF, Inc.","Joseph ALF, Inc." +70M004,ALF,12,Chinook Place,470 NE Oak St,"Madras, OR 97741",,"ASPEN COURT AID OPCO, LLC","ASPEN COURT AID OPCO, LLC" +70M005,ALF,48,Aspens (The),210 Roe Davis Ave,"Hines, OR 97738",,"Harney Pioneer Homes, Inc","Concepts in Community Living, Inc." +70M006,ALF,96,Summerplace Assisted Living Community,15727 NE Russell St,"Portland, OR 97230",,"Summerplace Assisted Living, LLC","Prestige Senior Living, LLC" +70M007,ALF,34,Astor Place,999 Klaskanine Ave,"Astoria, OR 97103",,"ASTOR AID OPCO, LLC","ASTOR AID OPCO, LLC" +70M008,ALF,49,Awbrey Place,2825 Neff Rd,"Bend, OR 97701",,"AWBREY AID OPCO, LLC","AWBREY AID OPCO, LLC" +70M009,ALF,50,Bridgewood Rivers Assisted Living,1901 NW Hughwood,"Roseburg, OR 97470",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M010,ALF,45,Brookside Place,3550 SW Canal Blvd,"Redmond, OR 97756",,"Redmond ALF, Inc.","Concepts in Community Living, Inc." +70M013,ALF,34,Carriage Place,150 S Williamson Dr,"Prineville, OR 97754",,"CARRIAGE AID OPCO, LLC","CARRIAGE AID OPCO, LLC" +70M014,ALF,48,Churchill Estates Assisted Living,1919 Bailey Hill Rd,"Eugene, OR 97405",,"Churchill Management, Inc.","Churchill Retirement Services, LLC" +70M015,ALF,75,Cornell Estates Retirement and Assisted Living Residence,1005 NE 17th,"Hillsboro, OR 97123",,Cornell Investors Group Inc.,"Cornell Investors Group, Inc." +70M016,ALF,80,Brookdale Geary Street,2445 Geary St SE,"Albany, OR 97321",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +70M017,ALF,50,Brookdale McMinnville City Center,721 NE 27th St.,"McMinnville, OR 97128",,"Brookdale Senior Living Communities, Inc.","Brookdale Senior Living Communities, Inc." +70M018,ALF,53,Dallas Retirement Village Assisted Living,340 NW Brentwood St,"Dallas, OR 97338",,"Dallas Mennonite Retirement Community, Inc.",Life Care Services +70M019,ALF,36,Davenport Place,930 Oak St,"Silverton, OR 97381",,"DAVENPORT AID OPCO, LLC","DAVENPORT AID OPCO, LLC" +70M020,ALF,48,Deerfield Village Assisted Living,5770 SE Kellogg Cr Dr,"Milwaukie, OR 97222",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M021,ALF,50,Dorian Place Assisted Living Facility,375 N Dorian Dr,"Ontario, OR 97914",,"Dorian Place Operations, LLC","Milestone Retirement Communities, LLC" +70M022,ALF,36,Applegate Place,1465 East Central,"Sutherlin, OR 97479",,"Sutherlin ALF, Inc.","Concepts in Community Living, Inc." +70M023,ALF,77,Parkview Assisted Living,10801 NE Weidler,"Portland, OR 97220",,Oregon Baptist Retirement Home,Oregon Baptist Retirement Homes +70M024,ALF,70,Brookdale at Klamath Falls,2130 Eldorado Blvd,"Klamath Falls, OR 97601",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M025,ALF,60,Elliott Residence,390 Church St,"Sublimity, OR 97385",,"Janmaur I, L.L.C.",Marian Estates Support Services +70M026,ALF,48,Emerald Valley Assisted Living,4550 W Amazon Dr,"Eugene, OR 97405",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M027,ALF,44,Oregon Retirement Center,1010 NE 3rd,"Milton-Freewater, OR 97862",,"Evergreen Oregon Healthcare Orchards Retirement, LLC","Evergreen Healthcare Management, LLC" +70M028,ALF,60,Flagstone Retirement & Assisted Living,3325 Columbia View Dr.,"The Dalles, OR 97058",,"Flagstone Operations, LLC.","Milestone Retirement Communities, LLC" +70M029,ALF,48,Forest Grove Beehive,2122 Hawthorne,"Forest Grove, OR 97116",,"Forest Grove Beehive, LLC","Caring Places Management, LLC" +70M030,ALF,65,Gibson Creek Retirement & Assisted Living Residence,1615 Brush College Rd NW,"Salem, OR 97304",,"TLC West, L.L.C.",Bonaventure Senior Living +70M031,ALF,101,Gilman Park Assisted Living,2205 Gilman Drive,"Oregon City, OR 97045",,"FM Gilman, LLC","Frontier Management, LLC" +70M032,ALF,36,Grace Place,380 NW 6th Ave,"Estacada, OR 97023",,"GRACE AID OPCO, LLC","GRACE AID OPCO, LLC" +70M033,ALF,76,Grande Ronde Retirement Residence,1809 Gekeler Lane,"La Grande, OR 97850",,"FM Grande, LLC","Frontier Management, LLC" +70M034,ALF,79,Greenridge Estates At Mountain Park,4 Greenridge Dr,"Lake Oswego, OR 97035",,"Greenridge Estates at Mountain Park, LLC","Greenridge Estates at Mountain Park, LLC" +70M035,ALF,78,"Grove Assisted Living, The",2112 Oak St,"Forest Grove, OR 97116",,"The Grove Assisted Living, L.L.C.","Heights Management, Inc." +70M036,ALF,49,Harvest Homes,6921 N Roberts Ave,"Portland, OR 97203",,"Harvest Homes, Inc.","Harvest Homes, Inc." +70M037,ALF,75,Hearthstone Of Beaverton,12520 SW Hart Rd,"Beaverton, OR 97008",,"Hearthstone of Beaverton Operations, LLC","Hearthstone Management Services, LLC" +70M038,ALF,55,Regency Village at Redmond,3000 SW 32nd St,"Redmond, OR 97756",,"BD Redmond I, LLC","Regency Pacific Management, LLC" +70M039,ALF,85,Pacific View Assisted Living Community,1000 6th Ave West,"Bandon, OR 97411",,"Bandon Senior Living, LLC","Seasons Management, LLC" +70M040,ALF,63,Brookdale Hermiston,980 W Highland Ave,"Hermiston, OR 97838",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M041,ALF,37,Hillside Place,1400 SE 19th,"Lincoln City, OR 97367",,"HILLSIDE AID OPCO, LLC","HiLLSIDE AID OPCO, LLC" +70M042,ALF,52,Homewood Heights Assisted Living,17999 SE River Rd,"Milwaukie, OR 97267",,Homewoods Heights LLC,"Prestige Senior Living, L.L.C" +70M043,ALF,30,Willow Place,1307 N College,"Newberg, OR 97132",,"Assisted Living Facilities, Inc.","Concepts in Community Living, Inc." +70M044,ALF,60,Inland Point Retirement Community,2290 Inland Dr,"North Bend, OR 97459",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M045,ALF,40,Suncrest Place,300 Suncrest Rd,"Talent, OR 97540",,"JACKSON AID OPCO, LLC","JACKSON AID OPCO, LLC" +70M048,ALF,36,Junction City Retirement & Assisted Living Residence,500 E 6th St,"Junction City, OR 97448",,"FC Ranger OPS Junction City (OR), LLC","Frontier Management, LLC" +70M049,ALF,31,Juniper House,301 SW 28th Dr,"Pendleton, OR 97801",,"Assisted Living Facilities, Inc.","Concepts in Community Living, Inc." +70M050,ALF,36,Kilchis House,4212 Marolf Place,"Tillamook, OR 97141",,"Tillamook County CARE, Inc.","Tillamook County CARE, Inc." +70M051,ALF,50,Lancaster Assisted Living,4156 Market St NE,"Salem, OR 97301",,Lancaster Assisted Living LLC,"Senior Living Management, Inc." +70M052,ALF,36,Lancaster Village,4148 Market St NE,"Salem, OR 97301",,"Lancaster Village, LLC","Senior Living Services, Inc." +70M053,ALF,67,Lakeview Senior Living,2690 NE Yacht,"Lincoln City, OR 97367",,"Lakeview Operations, LLC","Westmont Living, Inc." +70M054,ALF,43,Rogue River Place,2437 Kane St,"Klamath Falls, OR 97603",,"Sage AID OPCO, LLC","Sage AID OPCO, LLC" +70M055,ALF,42,Macklyn Place,755 Elk Drive,"Brookings, OR 97415",,"MACKLYN AID OPCO, LLC","MACKLYN AID OPCO, LLC" +70M056,ALF,56,Magnolia Gardens Assisted Retirement Living,1425 Daugherty,"Cottage Grove, OR 97424",,Magnolia Gardens Assisted Retirement Living LLC,Magnolia Gardens L.L.C. +70M058,ALF,60,McKillop Residence,500 Conifer Circle,"Sublimity, OR 97385",,"Janmaur II, L.L.C.",Marian Estates Support Services +70M059,ALF,74,McLoughlin Place Senior Living,1153 Molalla Ave,"Oregon City, OR 97045",,"McLoughlin Place Operations, LLC","Milestone Retirement Communities, LLC" +70M060,ALF,52,Meadow Creek Village Assisted Living,3988 12th St SE,"Salem, OR 97302",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M061,ALF,60,Meadowbrook Place,4000 Cedar St,"Baker City, OR 97814",,"Meadowbrook Place Operations, LLC","Concepts in Community Living, Inc." +70M063,ALF,25,"Gardens at Laurelhurst Village, The",3060 SE Stark St,"Portland, OR 97214",,"Laurelhurst Operations, LLC","Laurelhurst Operations, LLC" +70M064,ALF,48,Neawanna By The Sea,20 North Wahanna Rd,"Seaside, OR 97138",,"FC Ranger OPS Neawanna (OR), LLC","Neawanna Care Properties, LLC" +70M065,ALF,44,Nehalem Bay House,35385 Tohl Ave,"Nehalem, OR 97131",,"Tillamook County CARE, Inc.","Tillamook County CARE, Inc." +70M066,ALF,61,Northridge Center,3737 S Pacific Hwy,"Medford, OR 97501",,"Northridge Center, Inc.","Northridge Center, Inc." +70M067,ALF,57,Bayside Terrace Assisted Living,192 Norman Ave,"Coos Bay, OR 97420",,"ARHC OCCOOOR01 TRS, LLC","FM Ocean Crest, LLC" +70M068,ALF,84,Oceanview Assisted Living Residence,525 NE 71st,"Newport, OR 97365",,"Newport Assisted Living, LLC","Westmont Living, Inc." +70M070,ALF,130,Brookdale Park Place - Tigard,8445 SW Hemlock St,"Portland, OR 97223",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M071,ALF,35,Parkhurst Place,2450 May St,"Hood River, OR 97031",,"PARKHURST AID OPCO, LLC","PARKHURST AID OPCO, LLC" +70M072,ALF,60,Parkland Village Retirement Community,3121 NE Cumulus Avenue,"McMinnville, OR 97128",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M073,ALF,115,Powell Valley Assisted Living Community,4001 SE 182nd Ave,"Gresham, OR 97030",,PVALC-LLC,"Care Wise Management, Inc." +70M074,ALF,137,Quail Run Assisted Living,2525 47th Ave SE,"Albany, OR 97321",,"Mennonite Home Of Albany, Inc.","Mennonite Home Of Albany, Inc." +70M075,ALF,29,Rackleff Place,655 SW 13th Ave,"Canby, OR 97013",,"Canby ALF, Inc.","Concepts in Community Living, Inc." +70M076,ALF,95,Redwood Heights Retirement & Assisted Living Community,4050 12th St Cutoff SE,"Salem, OR 97302",,"ARHC RHSALOR01 TRS, LLC","FM Redwood Heights, LLC" +70M077,ALF,118,Regency Park Assisted Living,8300 SW Barnes Rd,"Portland, OR 97225",,Regency Park Apartments Ltd Part.,"Regency Park Management, LLC" +70M078,ALF,56,Brookdale River Road,592 Bever Dr NE,"Keizer, OR 97303",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M079,ALF,40,Guardian Angel Homes,540 NW 12th St,"Hermiston, OR 97838",,"Hermiston Senior Care, LLC","Tailored Management Services, LLC" +70M080,ALF,180,Rose Schnitzer Manor,6140 SW Boundary St,"Portland, OR 97221",,Robison Jewish Home,Robison Jewish Home +70M081,ALF,95,Rosewood Park Retirement & Assisted Living Residence,2405 SE Century Blvd.,"Hillsboro, OR 97123",,"Rosewood Investors Group, L.L.C.","Rosewood ALF, LLC" +70M082,ALF,56,River Run Place,1155 Darlene Lane,"Eugene, OR 97401",,"River Run AID OPCO, LLC","River Run AID OPCO, LLC" +70M084,ALF,41,Silver Creek Assisted Living Facility,703 Evergreen Rd,"Woodburn, OR 97071",,"FC Ranger OPS Silver Creek (OR), LLC","Silver Creek Care Properties, LLC" +70M085,ALF,87,Skylark Assisted Living,900 Skylark Pl,"Ashland, OR 97520",,"Ashland Assisted Living, LLC","Mission Senior Living, LLC" +70M087,ALF,44,Spring Meadows Assisted Living Facility,36070 Pittsburg Rd,"St Helens, OR 97051",,Elderserv,"Concepts in Community Living, Inc." +70M088,ALF,63,Spring Valley Assisted Living,770 Harlow Rd,"Springfield, OR 97477",,"Cascade Living Group - Oregon, LLC","Cascade Living Group, Inc." +70M089,ALF,72,Spruce Point Assisted Living,375 9th St,"Florence, OR 97439",,"Spruce Point, Inc.",Prestige Care Inc. +70M091,ALF,38,Summit Springs Village,133 S Church Street - PO Bx 687,"Condon, OR 97823",,Summit Springs Village Corporation,Summit Springs Village Corporation +70M092,ALF,90,Suzanne Elise Assisted Living Facility,101 Forest Drive,"Seaside, OR 97138",,"Forest Drive Operations, LLC","Forest Drive Operations, LLC" +70M093,ALF,72,Tanner Spring Assisted Living,23000 Horizon Dr,"West Linn, OR 97068",,Sequoia Heights Capital Partners,"TS Management, LLC" +70M094,ALF,87,"Fountains At Town Center Village, The",8607 SE Causey Ave,"Happy Valley, OR 97086",,"TCV Employees, LLC","Generations, LLC" +70M095,ALF,70,"Oaks At Lebanon, The",621 West Oak,"Lebanon, OR 97355",,"FM Oaks, LLC","Frontier Management, LLC" +70M096,ALF,88,Regency Village at Bend,127 SE Wilson Ave,"Bend, OR 97702",,"BD Bend I, LLC","Regency Pacific Management, LLC" +70M098,ALF,42,Valley View Assisted Living,112 Valley View Dr,"John Day, OR 97845",,"Valley View Investors, LLC","Ageia Health Services, LLC" +70M099,ALF,92,Marquis Hope Village ALF,1589 S Ivy,"Canby, OR 97013",,"Marquis Companies I, Inc.","Marquis Companies I, Inc." +70M100,ALF,70,Marquis Forest Grove Assisted Living,3336 19th Ave,"Forest Grove, OR 97116",,"Marquis Companies II, Inc.","Marquis Companies I, Inc." +70M101,ALF,95,"Suites Assisted Living Community, The",1301 SE Parkdale Dr,"Grants Pass, OR 97526",,LSREF Golden Ops 26 (OR) LLC,"Frontier Management, LLC" +70M103,ALF,60,Wiley Creek Community,5050 Mountain Fir Street,"Sweet Home, OR 97386",,Mid-Valley Healthcare,"Aidan Health Services, Inc." +70M104,ALF,46,Willamette Manor,176 West C Street,"Lebanon, OR 97355",,"Willamette Manor, Inc.","Willamette Manor, Inc." +70M201,ALF,74,Brookdale Monmouth,504 Gwinn St E.,"Monmouth, OR 97361",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M202,ALF,80,Brookdale Eugene Alpine Springs,3760 N. Clarey St.,"Eugene, OR 97402",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M203,ALF,80,Clatsop Retirement Village,947 Olney Ave.,"Astoria, OR 97103",,Clatsop Care Center Health District,Clatsop Care Center Health District +70M204,ALF,56,Springs at Clackamas Woods ALF,14314 SE Webster Rd.,"Milwaukie, OR 97267",,"TSL Clack OPS, LLC","The Springs Living, LLC" +70M205,ALF,54,Providence Benedictine Orchard House,550 S Main St.,"Mt. Angel, OR 97362",,Providence Health & Services - Oregon,Providence Health & Services - Oregon +70M206,ALF,61,Pheasant Pointe Assisted Living Community,835 E. Main Street,"Molalla, OR 97038",,"ARHC PPMOLOR01 TRS, LLC","FM Pheasant Pointe, LLC" +70M207,ALF,57,Regency Village at Prineville,830 North Elm Street,"Prineville, OR 97754",,"BD Prineville I, LLC","Regency Pacific Management, LLC" +70M208,ALF,70,Avamere Living at Newberg,730 Foothills Drive,"Newberg, OR 97132",,"Genesis Newberg Operations Company, LLC","Genesis Newberg Operations Company, LLC" +70M210,ALF,72,Orchards Assisted Living,1018 Royal Court,"Medford, OR 97504",,"Medford Assisted Living, LLC","Woollard Ipsen Management, LLC" +70M211,ALF,74,Prestige Senior Living Riverwood,18321 SW Pacific Hwy,"Tualatin, OR 97062",,CHP Tualatin-Riverwood OR Tenant Corp,"Prestige Senior Living, LLC" +70M212,ALF,48,East Cascade Retirement Community,175 NE 16th Street,"Madras, OR 97741",,"East Cascade Retirement Community, LLC","Senior Housing Managers, LLC" +70M213,ALF,68,Princeton Village Assisted Living Residence,14370 SE Oregon Trail Drive,"Clackamas, OR 97015",,"ARHC PVCLAOR01 TRS, LLC","FM Princeton, LLC" +70M216,ALF,54,Macdonald Residence,605 NW Couch Street,"Portland, OR 97209",,Macdonald Residence Limited Partnership,"Mennonite Management Services, Inc." +70M217,ALF,95,Aspen Ridge Retirement Community,1010 NE Purcell,"Bend, OR 97701",,"FM Aspen Ret, LLC","Frontier Management, LLC" +70M218,ALF,85,Avamere at Waterford Assisted Living Facility,760 Spring Street,"Medford, OR 97504",,"Waterford Operations, LLC","Waterford Operations, LLC" +70M219,ALF,65,"Springs at Mill Creek, The",1201 W 10th Street,"The Dalles, OR 97058",,"HSRE-Springs II at the Dalles, LLP","The Springs Living, LLC" +70M220,ALF,49,Redwood Terrace,3111 Canal Ave,"Grants Pass, OR 97527",,"Oregon Heights, LLC","Concepts in Community Living, Inc." +70M221,ALF,46,Prairie House Assisted Living Community,51485 Morson Street,"La Pine, OR 97739",,"Assisted Living Alternatives, Inc.",Ridgeline Management Co. +70M222,ALF,62,Cedar Village Assisted Living Community,4452 Lancaster Dr. NE,"Salem, OR 97305",,"ARHC CVSALOR01 TRS, LLC","FM Cedar Village, LLC" +70M223,ALF,56,Settler's Park Assisted Living Community,2895 17th St.,"Baker City, OR 97814",,LSREF Golden Ops 26 (OR) LLC,"SLH Rainier Manager, LLC" +70M225,ALF,76,Oak Park Assisted Living Community,1400 NE Rocky Ridge Dr.,"Roseburg, OR 97470",,"Roseburg Assisted Living, LLC",Bonaventure Senior Living +70M226,ALF,62,Brookdale Springfield Woodside,4851 Main Street,"Springfield, OR 97478",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M227,ALF,65,Avamere at Sherwood Assisted Living Facility,16500 SW Century Dr.,"Sherwood, OR 97140",,"Avamere Sherwood Operations, LLC","Avamere-Sherwood Operations, LLC" +70M228,ALF,55,Cascadia Village Retirement Comm.,39495 Cascadia Village Drive,"Sandy, OR 97055",,"Sandy Assisted Living, LLC",Bonaventure Senior Living +70M229,ALF,86,Callahan Village,1801 Garden Valley Blvd.,"Roseburg, OR 97470",,LSREF Golden Ops UE (OR) LLC,"Frontier Management, LLC" +70M230,ALF,75,Pelican Pointe Assisted Living Community,615 Washburn Way,"Klamath Falls, OR 97603",,"ARHC PPKLAOR01 TRS, LLC","FM Pelican, LLC" +70M231,ALF,65,Avamere at Sandy Assisted Living Facility,17727 SE Langensand,"Sandy, OR 97055",,"Avamere-Sandy Operations, LLC","Avamere-Sandy Operations, LLC" +70M233,ALF,53,Morrow Heights Retirement & Assisted Living Community,176 Wards Creek Road,"Rogue River, OR 97537",,LSREF Golden Ops 14 (OR) LLC,"Frontier Management, LLC" +70M234,ALF,70,Brookdale Eagle Point,261 Loto Street,"Eagle Point, OR 97524",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M236,ALF,79,Brookdale Rose Valley Scappoose,33800 SE Frederick Street,"Scappoose, OR 97056",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M237,ALF,36,Nyssa Gardens Assisted Living Facility,1101 Park Avenue,"Nyssa, OR 97913",,Malheur Memorial Hospital District,Malheur Memorial Health District +70M238,ALF,60,McKay Creek Estates,1601 Southgate Place,"Pendleton, OR 97801",,"Pendleton Ventures, L.L.C.","Prestige Senior Living, L.L.C." +70M239,ALF,80,Courtyard at Mt. Tabor,6323 SE Division,"Portland, OR 97206",,"Courtyard Assisted Members, LLC","Integral Senior Living, LLC" +70M240,ALF,75,Prestige Senior Living Huntington Terrace,1410 NE Cleveland,"Gresham, OR 97030",,CHP-Gresham-Huntington Terrace OR Tenant Corp.,"Prestige Senior Living, L.L.C" +70M241,ALF,53,High Lookee Lodge,2321 Ollallie Lane PO Box 6,"Warm Springs, OR 97761",,Confederated Tribes of Warm Springs Reservation of Oregon,Confederated Tribes of Warm Springs Reservation of Oregon +70M242,ALF,85,Lone Oak Assisted Living Facility,2615 Lone Oak Way,"Eugene, OR 97402",,LSREF Golden Ops 14 (OR) LLC,"Frontier Management, LLC" +70M243,ALF,75,Prestige Senior Living Beaverton Hills,4525 SW 99th Avenue,"Beaverton, OR 97005",,CHP Beaverton OR Tenant Corp,"Prestige Senior Living, LLC" +70M245,ALF,75,Avamere at Hillsboro Assisted Living Facility,2000 SE 30th Ave.,"Hillsboro, OR 97123",,"Avamere Hillsboro Operations, LLC","Avamere-Hillsboro Operations, LLC" +70M247,ALF,60,Cambridge Terrace Assisted Living,2800 14th Ave. SE,"Albany, OR 97321",,Albany Assisted Living LLC,Mountain West Retirement Corp. +70M248,ALF,97,Sun Terrace Hermiston,1550 NW 11th St.,"Hermiston, OR 97838",,Clay Davis Stroud - Oregon LLC,"Regency Pacific Management, LLC" +70M250,ALF,68,Deer Meadow Assisted Living Community,1350 W Main St,"Sheridan, OR 97378",,Aspen Foundation III,Aspen Foundation III +70M251,ALF,75,Brookdale Stayton,2201 3rd Ave.,"Stayton, OR 97383",,Emeritus Corporation,"Brookdale Senior Living Communities, Inc." +70M252,ALF,38,Laurelhurst House,15 SE 55th Ave,"Portland, OR 97215",,"Laurelhurst House, LLC","Touchstone Communities, LLC" +70M253,ALF,51,Ridgeview Assisted Living Center,872 Golfview Drive,"Medford, OR 97504",,"Ridgeview Assisted Living Center, LLC","Ridgeview Assisted Living Center, LLC" +70M254,ALF,90,Brookdale Grants Pass Village,1420 Redwood Circle,"Grants Pass, OR 97527",,"S-H OpCO Spring Village, LLC","Brookdale Senior Living Communities, Inc." +70M255,ALF,55,Woodland Heights,9355 SW McDonald St.,"Tigard, OR 97224",,"Woodland Heights, LLC","Woodland Heights, LLC" +70M256,ALF,55,Wildflower Lodge Assisted Living Community,508 16th St.,"LaGrande, OR 97850",,LSREF Golden Ops 14 (OR) LLC,"SLH Rainier Manager, LLC" +70M257,ALF,79,Marie Rose Center Assisted Living,17360 Holy Names Drive,"Lake Oswego, OR 97034",,"Mary's Woods at Marylhurst, Inc.","Mary's Woods at Marylhurst, Inc." +70M258,ALF,70,Avamere Living at St. Helens,2400 Gable Rd.,"St. Helens, OR 97051",,"Avamere - St. Helens Operations, LLC","Avamere-St.Helens Operations, LLC" +70M313,ALF,84,"Springs at Tanasbourne II, LLC",1950 NW 192nd Avenue,"Hillsboro, OR 97124",,"Springs at Tanasbourne II, LLC","The Springs Living, LLC" +70M350,ALF,119,"Village at Keizer Ridge, The",1165 McGee Court,"Keizer, OR 97303",,"VKR, LLC","Keizer Care Properties, LLC" +7MU215,ALF,126,St. Anthony Village,3560 SE 79th Avenue,"Portland, OR 97206",,St. Anthony Village Associates LP,SAGE +0O0O0O,,100,Fake Facility,1234 Fake St,"Nowheresville, NY 05400",,Fake Company,"Not a Company, LLC" \ No newline at end of file